Subject: gay men with AIDS in Rural America
From: [email-masked]
Date: Sun, 9 Nov 1997 09:37:53 -0500 (EST)

Gay Men With AIDS in Rural America
Michael Shernoff, MSW

  1997 Michael Shernoff
The Journal of Lesbian and Gay Social Services, V.7, No.1, November, 1997

Abstract

Some gay men spend their entire lives living in small towns or rural areas.
Many more grow up there and emigrate to large cities, with some returning
to the communities they grew up in when they become symptomatic with
AIDS. Gay men living in rural areas face different obstacles than those 
living in large urban centers with well defined gay communities.  When a 
rural gay man comes down with HIV or AIDS his problems in gaining access 
to needed medical and social services is even greater than his urban 
counterpart.  This article details the difficulties encountered by rural gay 
men living with HIV/AIDS. It reviews some of the research on rural 
individuals living with HIV and discusses how this pertains to gay men in 
particular.  In addition, some suggestions for meeting the social service 
needs of this population are offered.

INTRODUCTION
Epidemiologic research demonstrates that there are increasing numbers of 
people living with HIV and AIDS in rural America (Gardner et al., 1989; Lam
& Liu, 1994). The Centers for Disease Control and Prevention reported 
that through December, 1994, non-metropolitan areas of the U.S. contained
more than 22,800 cases of full blown AIDS (CDC, 1994). As Heckman et al.
(1996a) noted:

        The growing incidence of AIDS and new HIV cases has led to the 
        realization on that many rural communities are inadequately prepared 
        to address many of the problems associated with HIV/AIDS including 
        increasing numbers of openly gay men returning to the communities 
        where they grew up. For example, the escalating number of HIV/AIDS 
        cases has resulted in increased demands on rural health care 
        facilities, many of which were financially unstable even before the 
        emergence of AIDS.......because many rural communities have not 
        encountered large numbers of persons living with AIDS, little 
        consideration has been given to establishing sources of social 
        support for individuals and families affected by HIV/AIDS, and 
        organized public health HIV prevention efforts are essentially 
        nonexistent in rural areas.  Finally as HIV/AIDS becomes more 
        prevalent in rural communities, the stigma and prejudice associated 
        with the disease continues to grow in rural America. (p.37 ) 

This article details the difficulties encountered by rural gay men living
with HIV/AIDS. It reviews some of the research on rural individuals living
with HIV and discusses how this pertains to gay men in particular.  In
addition, some suggestions for meeting the social service needs of this 
population are offered. People with AIDS in rural America generally fall
into one of two groups.  They either have been born, grown up and remained
living in rural areas for the majority of their lives, or they have emigrated
to the big cities in order to escape small towns, but following their
diagnosis of AIDS, return home to live out their final days.  Both groups
include gay identified men, as well as men who do not identify as gay
but who regularly have sex with other men.

As Gunter (1988) noted "almost nothing is known about the lives of rural
lesbians and gay men and the barriers they encounter when in need of social
services."(p.49)  Similarly little is known about how people living with
HIV and AIDS in rural areas fare in terms of medical and psychosocial 
care. Heckman (1996a) stated that "very few, if any, studies have examined
strategies that might improve quality of life for rural persons with HIV/AIDS
who live with their family, relatives or a significant other." (p.37)
The myriad biopsychosocial issues involved in caring for  people 
living with HIV and AIDS, their families and other loved ones is described
in My own country: A doctor's story of a town and its people in the age
of AIDS (Verghese, 1994). Verghese depicted  treating a variety of people
with HIV and AIDS in a small town in the center of the bible belt, on the
Tennessee West Virginia border. 

Moses and Buckner (1980) identified clients' isolation and fear of discovery
as gay or lesbian as major obstacles facing rural lesbians and gay men
in need of social services. They elaborated upon specific issues that 
professionals need to consider when providing services to this population
including: clients' misconceptions and attitudes; lack of resources and 
information systems; limited options and alternatives and the need for the
worker to realistically assess the situation.  The author's experience 
in working with clients who left New York City to return to rural parts of
the country in the later stages of AIDS, and research conducted by Heckman
and his colleagues (1996a, 1996b) confirmed that the same issues hold
true for people with HIV/AIDS, their families and care givers in nonurban
parts of the United States in 1996.  Heckman et al. (1996a) noted that 
"several barriers to life-care services impacting rural persons with HIV/AIDS
include the lack of adequately trained medical specialists; geographical
ical distances and isolation from sources of social support; insufficient
or unreliable sources of transportation; and the lack of a cohesive support
community for infected gay men and women." (p. 37 )

Gunter (1988) delineated problems complicating service delivery to rural 
gay men and lesbians.  These problems often prevent people living with 
HIV/AIDS from receiving effective services.   According to Gunter "a major 
problem lies with the method of delivery when providers insist on utilizing
traditional service models based on an individuals's ability to access
the service.  It is fairly evident that this method has been ineffective
with the elderly in rural areas in terms of the delivery of health services
and social services." (p. 50)  She went on to say that providers need
to do more than just modify urban interventions or treatment approaches 
because it cannot be assumed that individuals have a choice as to available
service systems.  Thus people with HIV/AIDS living in a rural environment
must face the traditional rural problems associated with the unavailability
of services, lack of transportation, lack of information and resources,
and lack of responsive educational, health care, and social service
systems.  Gunter also explained "when these resources are needed, the lack
of them is compounded by the reality that rural areas are more conservative,
ingrown, traditional, religious and less tolerant of diversity." (p.50)

Given these barriers, addressing the needs of rural gay men with HIV/AIDS,
their families and significant others becomes more than just adapting urban
models of services to a rural setting. Rural people living with HIV/AIDS
face the same barriers to receiving services that affect all rural lesbians
and gays.  First and foremost is the lack of access to informational
systems that would aid them in securing necessary supports and services.
A major difficulty is the reluctance of many gay people and people with
HIV/AIDS to utilize what services are available because of two concerns:
the issue of confidentiality and the lack of trustworthy professional
providers to whom an individual can go for sensitive and competent help.

CONFIDENTIALITY AND SOCIAL SUPPORT
Gunter (1988) cautioned that "confidentiality is a difficult issue within
the rural environment.  Because of the limited geographic boundaries and
'incestuous' nature of the systems, personal associations, work and leisure
time activities and work patterns are usually well known to all in the
community.  The high level of visibility places the individual in jeopardy,
particularly when receiving health and welfare services." (p.50)  Gunter
also stated that in rural communities due to funding problems, many 
agencies utilize paraprofessionals and volunteers as staff members. In these
agencies there is a legitimate fear on the part of the individual seeking
services that he/she may be disclosed by these paraprofessionals to 
others both within the agency and to community members.  "For some reason,
paraprofessionals, volunteers and nonprofessional workers in rural 
communities appear not to feel bound by the rules of confidentiality." 
(Gunter, 1988, p. 51) In tight knit nonurban communities entire families may 
be stigmatized by having a member with HIV/AIDS, effectively depriving them
of much needed support during their time of crisis. Heckman and colleagues
(1996b) found that discrimination and prejudice among community members
does not only affect the HIV infected or AIDS diagnosed individual.  One
participant in their study described how a family had difficulty arranging
a funeral for a son who had died of AIDS, because the church pastor refused
to bury their child.

Heckman et al. (1996b) reported that rural clients with HIV/AIDS have great
difficulty gaining access to social support.  One study participant indicated
that "in addition to the person living with HIV/AIDS lacking a similar
other to confide in, community residents often believe that persons
living with AIDS should move away to the city, thus removing the problem
of AIDS from their rural community.  This apathy and resistance among 
community members greatly impeded clients' efforts to obtain social and 
emotional support, exacerbating the problems of loneliness and isolation." 
( p. )

Gunter (1988) explained that in rural areas there are informal systems that
in many cases, actually provide many of the social services for individuals
or families.  Crisis intervention, child-care, emotional and financial
support and in-home health care are often provided by these informal 
networks.  When these systems have not broken down due to homophobia or 
fear of AIDS, they provide the very essence of the quality of care that 
draws numbers of people with HIV/AIDS to return to the communities in which
they were raised.  The informal network in rural areas is usually composed
of family, friends, neighbors, organizations and religious institutions -
all of which may be denied the openly gay individual and his family who
has either self-identified or been involuntarily identified as having 
HIV/AIDS. 

Heckman et al. (1996b) documented that unlike many of their urban 
counterparts, rural persons living with AIDS rarely have close friends to 
whom they can turn, nor do they have a gay community in which they can seek 
support and social companionship.  Their research found that in many small 
towns, there is only one person in the immediate area who is living with AIDS.
One of the participants in their study noted, "a person with AIDS in
a rural area can't talk to just anyone about their [sic] condition, because
if the wrong people find out you're infected, your life will be more
hell than it already is." (p. )

HEALTH CARE FOR PERSONS WITH HIV/AIDS IN RURAL AMERICA
Heckman (1996a) identified long distances to medical facilities and personnel
as a major barrier to care for rural persons living with HIV/AIDS. Verghese
(1994) recounted that in the community in which he was practicing
colleagues were reluctant to accept referrals of patients with HIV/AIDS.
Within the hospital, nurses and support staff were often unwilling to provide
basic services out of fear or moral judgement regarding how people 
contracted the disease. Many rural health care professionals decline to 
provide direct care to people with AIDS because they do not feel adequately
educated in the area of AIDS treatment ( Lockman-Samkowiak, 1994),  while
others are concerned that current and potentially new patients will be
scared off because he or she treats people living with AIDS (Berry et al,
1995). Heckman (1996a) reported that most rural states are unlikely 
to have the experience or financial or logistical preparations for the growing
number of rural AIDS cases.  In the same aricle these authors noted
that several states have recognized these deficits and are currently 
evaluating a model that links rural satellite health care clinics with urban
facilities.  In this model, physicians experienced in AIDS diagnosis and
treatment, most of whom practice in urban settings, periodically visit 
satellite clinics to train and consult with local physicians.  As a result,
local residents living with HIV/AIDS receive care close to their place 
of residence and physicians in the region receive information and hands-on
training they otherwise would not receive.  Heckman (1996b) also 
explained that the problem of health care service accessibility is not due 
exclusively to a shortage of health care professionals in rural areas, but 
also to the lack of personal and public transportation in rural areas. They
found that it was common for rural persons living with AIDS to not have 
a valid driver's license. As they concluded "these factors, taken together,
greatly complicate efforts to access health and social services."(p. )

Heckman's research (1996b), documented that the prevalence of dual 
diagnoses in rural areas was problematic, and that many rural clients in 
addition to having a diagnosis of HIV/AIDS, were living with a substance 
abuse or mental health problem.  The participants in this study reported that 
conflicting economic priorities made it increasingly difficult to provide 
adequate treatment to clients with a dual diagnosis because there was a 
scarcity of resources for long term alcohol or drug addiction counseling.
One attempt to address the needs of rural people living with HIV/AIDS and
their caregivers was the National Rural AIDS Conference, first held in 
early 1995 in St. Cloud, Minnesota, and now held annually. Heckman and his
colleagues surveyed 57 attendees of this conference to identify barriers
to care for rural persons living with AIDS and strategies that may improve
their quality of life (1996b). In a study conducted through telephone
interviews with key informants in all of a midwestern state's AIDS service
organizations Heckman and colleagues (1996b) identified the following 
circumstances confronting persons living with HIV/AIDS in rural areas: 
increased isolation and loneliness; difficulty gaining access to health care
services; and increased community perceptions of hatred and prejudice. 
These researchers documented quality of life improvement programs being 
implemented in rural areas by community-based organizations. These 
organizations ensure that close relationships are maintained among case 
managers and clients, conduct emotional and social support groups for persons 
living with HIV/AIDS, and facilitate client access to complementary therapies
(Heckman et al 1996b).

PREPARING TO MOVE FROM A CITY TO RURAL AMERICA 
In the author's practice in the past four years, three psychotherapy 
patients returned to rural communities in the final phase of HIV illness. 
Conversations with eleven colleagues with large numbers of persons with 
HIV/AIDS in their psychotherapy practices in seven different large cities 
revealed that all but one had patients with advanced AIDS return to small 
towns or rural areas near the end of their lives. There is a growing need for
health care professionals and community leaders in rural areas to become
trained in meeting the biopsychosocial needs of individuals and families
affected by AIDS who are already living in their communities, and who 
will continue to return to the communities where their families live.
When a gay man who had chosen to leave a rural area to live in a large city
decides to return because he has HIV/AIDS, most often he is returning 
to a family and/or community who will negatively judge his life style.  Thus
for all of the reasons mentioned above, this is not a decision that is
made casually or impulsively. Mental health professionals need to be 
prepared to help a client assess the cost benefit ratio of moving from a city
to a rural area.  In addition to the psychotherapeutic and counseling 
issues that must be addressed, the therapist should identify and locate any
available local resources and adequate health care services prior to the
client's departure. When a client currently is receiving home infusion
services this may help the therapist to identify   local resources, because
the home nursing company often knows of a local affiliate near to the
client's new location.  The local office of the nursing company will most
likely be able to provide a referral to the local physician or health care
facility that is skilled in serving people with AIDS. 

In addition to taking on this case management role, the therapist or 
counselor must begin a thorough exploration of the emotional issues 
surrounding leaving and how these will affect the client. This is often 
terribly difficult for both the client and therapist because much of the work 
will involve discussions of multiple losses, and feeling powerless to control 
one's life. Therapists must be alert to understandable countertransference
regarding feelings about losing the client due to the move prior to his
impending death. During these sessions the therapist needs to explore 
whether the client will desire to continue contact or even regular sessions
with the therapist via telephone.  For some, this telephone contact will
be the only remaining connection with their former life. In addition to 
the emotional support such ongoing phone contact can provide, it often is
a useful resource for practical problem solving.   

In almost all cases, individuals who make the decision to return to a rural
community feel that they no longer have any other option for maintaining
a reasonable quality of life and for being adequately taken care of if
they remain living in their present circumstances.  This recognition often
is accompanied by intense anger and sadness. Both the final face-to-face
therapy sessions as well as subsequent telephone sessions can be critical
for helping the client to manage these feelings. Some of the individuals
who return to small towns are the last surviving member of an entire 
friendship network that has been devastated by AIDS, and there is simply 
no one left other than paid attendants to care for him in this crucial time
of his life.  When an individual does not have large financial resources,
or entitlements that will provide him with care, there literally may 
be no one upon whom he can depend for assistance in shopping, cooking, 
cleaning and transporting him to and from medical appointments.  

In therapy sessions prior to returning to live with family members, some
clients have reported feeling like a failure since they do not see any other
option besides returning to their families.  In these cases, in addition
to the ordinary anger about having AIDS and all the accompanying losses,
there is the anger of feeling trapped into needing to return home to
parents with whom there may be at best an ambivalent relationship.  Some
people have discussed feeling as if returning home to their parent's house
to die somehow invalidates their lives as grown ups who lived a 
self-actualized gay life. As one patient who had nursed his lover and best 
friends through their illnesses put it, "I can't help but feel that if somehow
I had done something, don't ask me what, differently I wouldn't now be 
facing the prospect that the only place I have to go to die is my parent's
home. It makes me feel like my life was a failure," he said sobbing on 
the eve of his departure for rural Oklahoma.

In cases where families have accepted a son's homosexuality and AIDS 
diagnosis, returning to one's family of origin provides the opportunity for 
final familial reconciliation and healing of old wounds.  Even when this is
the case, many patients express fears of being infantalized by their parents
because they are critically ill, in need of a great deal of assistance,
and are returning to live in their parents' home.  It is a difficult
balance for parents to maintain in terms of respecting the adulthood and
autonomy of an adult child who is in reality once again physically, 
emotionally and possibly financially dependent upon mom and dad. One way 
of trying to deal with this prior to the client's returning home is by offering
to have telephone conference calls with the client, his or her family,
and the therapist to address some of these issues before the person with
AIDS arrives.  These family conference calls can also help begin to prepare
the family for the practical and emotional realities and demands of caring
for a loved one with AIDS who is returning home to live out his or 
her final days.  Once the family member has returned home,  these telephone
sessions may be the only source of support for the person with AIDS as
well as his or her family.

During these sessions,  possible local avenues of support for both the 
family and client can be explored that might have been over looked.  The 
parents of one client who was planning to return to rural Georgia had not 
told anyone about their son's diagnosis.  In a telephone session with the 
mother and client before he left New York, the therapist suggested that the
mother consider sharing the reasons for her son's impending return with
her husband's parents who lived nearby, and with her minister who she had
reported was "pretty liberal." During the final telephone session before
the client's departure, she joyously reported that she was at last 
confident of her ability to manage whatever lay ahead. Her in-laws were 
shocked, and devastated, but totally supportive and offered to do everything 
they could to help.  The minister was also kind and solicitous and preached
a sermon the following Sunday about the need for Christian compassion 
for all people with AIDS.  He assured her of his continuing availability 
to their entire family as a friend, pastoral counselor and spiritual advisor.
As a result, the parents felt emotionally prepared for the burdens ahead.
In addition, this phone call reassured the client of a  welcoming 
environment, thus decreasing his fears about returning to rural Georgia.

MAINTAINING SUPPORT 
Sometimes these telephone sessions help the family activate local support 
in response to a crisis. During a medical emergency the local hospital had
refused to treat the client described above, and after giving him a 
portable oxygen tank, sent him to a hospital an hour's drive away.  The 
mother telephoned the therapist in New York enraged and frightened. At the 
therapist's urging, she confided the incident to her minister, who upon 
hearing it immediately called another parishioner who was the CEO of the 
offending hospital and without revealing the name of the family involved, 
reported what had happened.  Two days later, the CEO told the minister that
the doctors and nurses had felt unprepared to treat a person with AIDS.

Upon hearing this the minister asked if there had been any mandatory in
service trainings on medical management of people with HIV /AIDS for the 
hospital staff.  The administrator acknowledged that there had not been any.
The minister strongly suggested that the administrator gather his 
deptartment heads and insist that trainings be offered to each staff person in
the hospital to avoid a recurrence of the kind of incident that had brought
this to both of their attention.  As a result, the local hospital began
trainings by outside experts in caring for people with HIV/AIDS.  

Some families may use the return of their son as a way of blackmailing him
into repenting for a life they think of as sinful. They may extort promises
of becoming born again in return for a place to be taken care of and
die. In these situations the son's feelings of guilt, unresolved internalized
homophobia, worthlessness, and powerless are triggered as is his rage
at needing to submit to his family's demands.  Another man who returned
to the same small town in rural Georgia from Manhattan as the client 
described above, expressed his feelings in the following manner. 

        "Originally I thought that I was returning to my parents' home so I 
        could die with dignity.  	Sure, I'll have a physically comfortable 
        place to live and people who will take care of me, but at what cost 
        to my self-respect and integrity? I really have to wrestle with the 
        question, is the physical comfort worth the emotional toll it will 
        take on my self-esteem to pretend that I regret having lived the 
        life that was so meaningful and joyous for fifteen years! How ironic 
        that my parents really believe that they are offering me the finest 
        Christian charity by allowing me to return to their home, but only 
        if I agree to all of their conditions." 

Heckman's study (1996a) found that face-to-face support groups for rural 
people with AIDS were a crucial element to improving their quality of life,
and  "while establishing and maintaining such groups in rural areas is
not always easy, persons interested in joining or establishing a face-to-face
support group for those affected by HIV/AIDS, the local rural AIDS 
action network (RAAN) or Red Cross agency is a logical place to begin." 
(p. 42) For people living with HIV/AIDS in remote rural areas who are 
geographically isolated, Rounds et al. (1991) suggested that 
telephone-linked support groups can be used to network people with AIDS to 
others who are unable to travel to a  group meeting.

An additional resource is the AIDS and gay/lesbian chat rooms on the Internet.
This is a way that isolated rural gay men can maintain contact with
other people around the country and perhaps even discover other gay people
or people with HIV/AIDS who live nearby with whom they can develop 
friendships and mutual support systems. 

As Tartaglia (1996) stated, local religious communities are potentially 
important allies in the effort of creating collaboration among professionals
and the existing natural support systems for rural people living with 
HIV and AIDS, because they are historically and functionally among the most
influential of rural institutions. To support people with HIV and  publicity
to be identified as sympathetic to this issue, clergy can implement
educational and service-related interventions for the community, the 
congregation, and families.  Tartaglia also suggested that "clergy are in a 
unique position to know the private struggles of individuals and families
who may secretly carry the burden of HIV disease or having gay children.

They can, with permission, connect congregants who live in isolation and
who experience fear, guilt and grief." (p. 6)  Having a traditionally hostile
or at best nonsupportive institution like a church actively function
as an extended family for a gay man with AIDS can have enormous healing
and redemptive powers for the individual approaching the end of his life.

CONCLUSION
Research confirms that both people living with HIV/AIDS and those who care
for them in rural America find that life is more difficult for a variety
of reasons than for those living with HIV/AIDS in large urban centers. 
This is especially true if the person with HIV/AIDS is a gay man. Yet despite
this, the numbers of gay men with HIV/AIDS in nonurban parts of the
United States continue to increase and show no indication of abating. In
the second decade of the AIDS epidemic there are finally rudimentary services
in place to help care for them, yet local communities are overwhelmingly
ill prepared to serve this population, and remain generally apathetic
and even hostile towards those affected by the disease.  

Several additional areas of research seem fertile for exploration by social
scientists and graduate students of public health, social work and 
psychology. Some suggested areas for research are: What are the 
demographics of people living with HIV/AIDS in different parts of rural 
America, and is there any discernable difference in the prevalence of racial 
and sexual orientation breakdown of people living with HIV/AIDS in different 
parts of the rural United States? A study of rural churches in different parts
of the country could attempt to ascertain how many have actually had a 
parishioner disclose that he or she had HIV/AIDS, and what was the response
of the minister and congregation. Is there any difference in levels of 
support by black and white rural churches, and is there any difference in
the amount of support based on the route of HIV infection? How many local
rural health departments, Red Cross, and other social service agencies 
have already developed needed medical and social services for people living
with HIV/AIDS? Were these efforts in response to an influx of cases of
HIV/AIDS, or prior to the emergence of identified cases in that particular
locale?   Similarly, how many rural medical institutions and social service
agencies have actually begun to implement staff and community education
programs about HIV/AIDS?  Where training programs have been offered,
is there a component on cultural diversity that includes ways to minimize
the heterocentric bias of service providers who will come in contact with
gay male clients? When clients with HIV/AIDS reported community antagonism
or hostility towards them or their families, what role did clergy, medical
and social service professionals play in attempting to ameliorate 
these prejudices?  Research into any of the above topics is likely to shed
light on the social service needs of gay men with AIDS in rural America.

Urban mental health professionals who work with gay men with HIV/AIDS who
are thinking of returning to rural areas or small towns need to be prepared
to aid these individuals in a variety of ways.  Assistance in locating
local health care and social service resources in or near the locations
to which clients will be moving is paramount. It is a task that the person
with AIDS may not have the energy or cognitive ability to accomplish and
yet it can be a crucial first step in preparing for this all important
move.  Social workers, psychologists, and counselors can help locate 
existing social supports and make themselves available to continue either 
sporadic or regular contact with the client and his  family as seems 
necessary and appropriate.  Prior to the individual's departure issues 
pertaining to the move and feelings resulting form the circumstances that 
made such a decision inevitable need to be thoroughly explored, including 
attempts to work through long term family dynamics that may never previously 
have been resolved.  By insuring that all of these pieces are in place, AIDS
health care professionals and volunteers are doing everything possible 
to help the gay man living with AIDS make this inevitably trying and difficult
transition as smooth and painless as possible.

References 

Berry, D.E., McKinney, M.M., McClain, M., & Valero-Figueira, E. (1995).  
Rural HIV service networks: Patterns of care and policy issues. Office of
Science and Epidemiology, Bureau of Health Resources Development, Health
resources and Services Administration.

Centers for Disease Control and Prevention. (1994). HIV/AIDS surveillance
report, 6(2), 8-9.

Gardner, L., Brundage, J., Burke, D., McNeil, J., Visintine, R. & Miller,
R. (1989). Evidence for spread of the human immunodeficiency virus epidemic
into low prevalence areas of the United States. Journal of Acquired Immune
Deficiency Syndrome 2, 521-532.

Gunter, P. (1988). Rural gay men and lesbians: In need of services and 
understanding. In M. Shernoff & W. Scott (Eds.), The sourcebook on lesbian/
gay health care second edition (pp. 49-53). Washington, D.C.: The National
Lesbian/Gay Health Foundation.

Heckman, T., Somlai, A., Kelly, J., Stevenson, L. & Galdabini, K. (1996a).
Reducing barriers to care and improving quality of life for rural persons
with HIV. AIDS Patient Care and STDs, 11:37-43. =

Heckman, T., Somlai, A. & Otto-Salaj, L. (1996b). Community-based 
organizations' perceptions of quality of life among rural people living with 
HIV/AIDS. (Under review) American journal of community psychology.

Lam, N.S., & Liu, K. (1994). Spread of AIDS in rural America, 1982-1990. 
Journal  of Acquired Immune Deficiency Syndrome, 7, 485-490.

Lockman-Samkowiak, J. (1994).Care of patients with acquired immune 
deficiency syndrome in rural areas. Journal of Intravenous Nursing, 17, 
206-209.

Moses, A.E., & Buckner, J.A. (1980). The special problems of rural gay 
clients. Human services in the rural environment, 5(5). (Reprint found in A.
E. Moses and Robert O. Hawkins, Jr. (Eds.), (1982), Counseling lesbian
women and gay men- A life issues approach (pp. 173-180). St. Louis, 
Missouri: C.V. Mosby Co.

Rounds, K., Galinsky, M., & Stevens, L. (1991). Linking people with AIDS 
in rural communities: The telephone group. Social Work; 36, 13-18.

Tartaglia, A. (1996). AIDS and the rural church. FOCUS: A Guide to AIDS 
Research and Counseling, 11(4), 5-6.

Verghese, A. (1994). My own country: A doctor's story of a town and its 
people in the age of AIDS. New York: Simon & Schuster.

Michael Shernoff, MSW is in private practice in Manhattan, is adjunct 
lecturer at Hunter College Graduate School of Social Work. Correspondence 
can be sent via the Internet at [email-masked].

Key Words: AIDS, Rural, Gay Men, HIV