Background:
The South has an increasing number of rural HIV cases. Rural areas face many challenges, including limited access to healthcare services and stigma, which may lead to later HIV testing in rural residents.

Objective:
To investigate associations between place of residence and 1) disease stage at HIV diagnosis and 2) indication for HAART initiation at HIV diagnosis.

Method:
South Carolina residents newly diagnosed with HIV between 2001 and 2005 were included. Late HIV testing was defined as: clinical AIDS diagnosis within 12 months or an initial CD4+ cell count ≤ 200 cells/µL within 12 months. HAART indication was defined as an initial CD4+ cell count ≤ 350 cells/µL or viral load ≥ 100,000 copies/mL within 12 months. County of residence at HIV diagnosis was classified as rural or urban based on the US Census definition. Data were analyzed using logistic regression, adjusting for gender, race, mode of exposure, and age.

Result:
From 2001-2005, 4,117 individuals were newly diagnosed with HIV. Of these, 1,170 (28.4%) were rural residents, 2,944 (71.5%) were urban residents, and 3 (0.1%) had missing data. Among rural residents, 561 (47.9%) were late testers and 619 (52.9%) had an indication for HAART initiation, compared to 1,231 (41.8%) and 1,413 (48.0%) of urban residents, respectively. After adjustment, the associations of rural residence with late testing (OR=1.27, CI=1.10, 1.46) and with indication for HAART initiation (OR=1. 21, CI=1.05, 1.39) were significant.

Conclusion:
Rural residence is a significant risk factor for late HIV diagnosis and indication for HAART initiation. Early diagnosis is important because this leads to improved treatment response, reduced morbidity and mortality, and reduced transmission potential.

Implications:
These findings suggest that rural areas in South Carolina should be a target for more intensive HIV education and prevention efforts to reduce the proportion of late testers and improve HIV-related outcomes.