A study published in JAMA Network Open found that HIV transmission-associated behaviors in rural communities could be ascertained through surveys, especially in regards to individuals who use injected drugs and are sexually active.

Injection drug use is an increasingly common cause of HIV transmission in the United States, even as HIV is most often transmitted sexually, the authors noted. According to recent data, 67.8% of new diagnoses of HIV in the United States were in men who have sex with men. The HIV risk environment for people who use drugs (PWUD) who live in rural areas is not always clear, and different geographies and populations can have varying HIV transmission behaviors, so this study aimed to “describe the distribution of HIV transmission-associated behaviors among rural PWUD and how these may vary by individual-level characteristic and location.”

The study used a cross-sectional design to evaluate the results of a survey conducted from January 2018 to March 2020. The 8 project areas that participated in the Rural Opioid Initiative (ROI) were the areas targeted for the survey for PWUD in rural counties with high overdose rates in 10 states. Participants who lived in the study area, had used injection drugs or noninjection opioids to get “high” in the previous 30 days, were able to communicate in English, and were 15 years or older at 2 sites and 18 years or older at 6 sites were included in the study. All participants were recruited between January 2018 and March 2020.

All participants took an HIV test and completed a questionnaire that was collected by audio computer-assisted self-interview in 5 sites, a computer-assisted personal interview at 2 sites, and a computer-assisted self-interview at 1 site. Participant characteristics collected included site location, age, race, gender identity, sexual orientation, partnership status, and drug of choice.

There were 3048 PWUD who participated in the study who had a mean (SD) age of 36.1 (10.3) years. A total of 84.5% identified as White and 57.0% as men. Most participants were heterosexual (86.8%) and unpartnered (68.6%). Opioids were listed as a durg of choice for 53.9% of participants, stimulants for 41.5%, and 4.6% used other drugs.


Age (87.7% in younger participants vs 82.5% in older participants), drug of choice (82.0% using opioids vs 88.8% using stimulants vs 82.7% using other drugs), and site (range of 72.5% in Kentucky to 87.9% in Oregon with responses) were significant factors in the frequency of transmission behaviors associated with drug use. Injection also varied by race (92.9% of American Indian participants, 71.9% of Black participants, 85.0% of White participants, and 79.7% of participants of another race), as well as partnership status (82.8% partnered vs 85.8% unpartnered).

Younger age (odds ratio [OR], 1.52; 95% CI, 1.24-1.87) was associated with drug injection whereas bisexual orientation as associated with syringe sharing (OR, 2.37; 95% CI, 1.72-2.23).

There was variability across characteristics when it came to the frequency of transmission behaviors that were associated with sexual activity. Variability across characteristics was found in 7 behaviors by site, 6 behaviors by sexual orientation and partnership status, 3 behaviors varying by race, and 1 behavior by gender identity.

Increased odds of multiple opposite-gender women partners was found in participants who were younger (adjusted OR [aOR], 1.50; 95% CI, 1.12-2.01), were unpartnered (aOR, 2.37; 95% CI, 1.63-2.44), and reported stimulants as the drug of choice vs opioids (aOR, 1.52; 95% CI, 1.11-2.06). Increased odds of multiple opposite-gender men partners was found in participants who were younger (aOR, 2.00; 95% CI, 1.41-2.84), were bisexual (aOR vs heterosexual, 1.81; 95% CI, 1.23-2.65) or unpartnered (aOR, 2.22; 95% CI, 1.50-3.28), and reported stimulants as the drug of choice (aOR vs opioids, 1.49; 95% CI, 1.04-2.14).

There were some limitations to this study. Temporal associations could not be studied due to the cross-sectional design of the study. The study used peer recruiting, which could have led to the recruitment of very similar participants. The ROI focused on opioids but the drug of choice for many participants was stimulants, which makes the association of stimulant use hard to estimate. Adjustments were not made for multiple comparisons. Sample sizes and recruitment methods between sites were different.

The researchers concluded that the ROI was able to give valuable data in learning about behaviors associated with HIV transmission in rural areas.


Jenkins WD, Friedman SR, Hurt CB, et al. Variation in HIV transmission behaviors among people who use drugs in rural US communities. JAMA Netw Open. Published online August 21, 2023. doi:10.1001/jamanetworkopen.2023.30225