HIV infection rates are falling in many large U.S. cities, but rates are rising in much of rural America.

"There have of course always been cases of HIV in sparsely populated parts of the country, but in these places far from cities, the conditions that lead to HIV transmission are now intensifying — and rural America is not ready for the coming crisis," Northwestern University journalism professor Steven Thrasher writes for The New York Times. "Unlike large urban areas that have dealt with similar health and substance crises in the past, and that have networks of service providers and consumers in place, small rural health jurisdictions often lack the infrastructure to confront the crisis and have little history of dealing with comparable health issues."

The opioid epidemic is a major factor in the explosion of rural HIV infections, since opioid users are more likely to engage in risky behavior such as having unprotected sex while high or sharing needles. (Prescription opioid abusers often turn to higher-octane intravenous opioids like heroin.) In West Virginia's Cabell County and Huntington, for example, where there is a massive prescription opioid addiction problem, 80 new HIV infections have been diagnosed over the past year. "This avoidable crisis has been exacerbated by unemployment, declining coal mining production and economic pressures on regional press to act as effectively as a watchdog," Thrasher writes.

Most frustratingly, the rise in rural HIV infection rates was predictable, Thrasher writes: "After a hepatitis C and HIV outbreak in Scott County, Ind., in 2014 and 2015 that was fueled by deindustrialization and opioids, the CDC released a list of 220 counties similarly vulnerable to such outbreaks among people who use intravenous drugs. The densest concentration of those counties is along the Appalachian Trail, with 28 of them in West Virginia — more than half of the state’s 55 counties."

However, many rural areas are ill-equipped to prevent or deal with an HIV outbreak because they frequently refuse to effective policies such as needle-exchange programs, more comprehensive sex education, and LGBTQ+ public health efforts, Thrasher writes. Rural HIV patients also may be reluctant to admit they're infected or seek treatment because of the stigma associated with it. That leads to worse health outcomes and more infections. Thrasher says the problem "can't be ignored any longer."