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A hidden hazard of rural living

By Roger P. Smith, Ph.D.

Say "rural living," and it summons up an image of ruddy-cheeked good health. Could it be that living in the country is actually hazardous to your health? "Could be," says Dartmouth's Timothy Lahey, M.D., "if you also happen to be infected with HIV."

He and colleagues in the Section of Infectious Diseases identified two cohorts of HIV-positive patients in New England—317 in locales with a mean population of about 79,000 people (meeting the definition of urban set in 2004 by the federal government) and 327 in locales of less than 10,000 (areas considered rural). The two groups were followed from 1995 to 2005. All 644 patients were seen more than once in Dartmouth-Hitchcock clinics by clinicians in the same multidisciplinary group, which included infectious disease physicians and a full support staff of HIV-AIDS specialists.

Adjustments: Yet despite the fact that all received the same care, mortality was clearly higher in the rural group. Adjustments for age, sex, race, HIV risk factors, year of diagnosis, travel time,

Lahey suspects the differential may not be disease-specific.

lack of insurance, and treatment regimen had no effect on the result. The investigators, who published their findings in AIDS Research and Human Retroviruses, are at a loss regarding the reasons why.

But they believe it's reasons—plural— rather than a single explanation. Their data does help to separate the more likely from the less likely contributing causes. It is possible, for example, that living in a remote area might limit patients' access to high-quality health care. Or that the stigma associated with AIDS might impel HIV-positive patients to seek a distant provider for privacy reasons. Some variables—such as frequency of appointments, patientmigration patterns, and patient income—were not evaluated but might also play important roles.

However, Lahey suspects the urban-rural differential may not necessarily be disease-specific. He speculates that the

same result might be found for any disease with high mortality and a complicated treatment regimen, such as cancer or heart disease. If that is the case, then identifying the exact causes of the increased mortality in rural HIV patients would make it possible to design appropriate interventions that might apply to a wide variety of diseases. In other words, says Lahey, his rural HIV patients may be like canaries in a coal mine in their vulnerability to poor health outcomes.

Future studies: Lahey also points out that "in New England, there are often vast differences between two communities that might both be considered 'rural' by the government criterion—such as the difference between Hanover, N.H., and Colebrook, N.H. It is very difficult to capture such differences in a study of this kind." But, he says, there are more sophisticated tools—such as the Rural-Urban Commuting Area system, a 10-point scale—that the group may use in future studies to try to refine such distinctions.

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