Just over a decade ago, the small town of Austin, Indiana became the center of one of the largest HIV outbreaks associated with injection drug use in modern U.S. history. More than 200 people were diagnosed with HIV in a community of just a few thousand residents, many of whom were also living with Hepatitis C. I grew up about 50 miles from Austin, and watching that outbreak unfold never felt like witnessing an isolated event. It felt like seeing what can happen when longstanding gaps in healthcare access reach a breaking point.
Today, the geography of the HIV epidemic is changing. While new HIV infections have declined nationally by about 12% since 2018, the burden is becoming increasingly concentrated in the rural South, where healthcare infrastructure is often the most limited. The South accounted for 51% of all new HIV diagnoses in 2023 despite representing only about 38% of the U.S. population, and eight of the nine states with the highest HIV diagnosis rates are in the region. In tandem, HIV diagnoses associated with injection drug use have been increasing in rural America. Between 2016 and 2022, diagnoses attributed to injection drug use increased by nearly 30% in rural counties, even as they declined in large urban centers. Rural residents are also more likely to receive an HIV diagnosis at an advanced stage of disease, reflecting persistent barriers to routine testing, specialty care, transportation, and pharmacy access.
These trends are unfolding alongside broader changes in rural healthcare. More than 80% of U.S. counties have no infectious disease physician, with shortages concentrated in rural communities, while hospital closures and broader financial pressures have further reduced access to care. Federal and state governments have responded with unprecedented investments aimed at rebuilding rural health infrastructure. Although these programs are rarely HIV-specific, they support many of the capabilities and organizations that improve HIV prevention and treatment, including primary care expansion, telehealth, pharmacy services, behavioral health integration, workforce development, and care coordination.
One of the most significant of these investments is the Rural Health Transformation Program (RHTP), a $50 billion federal initiative administered by the Centers for Medicare & Medicaid Services (CMS). The program is designed to strengthen healthcare delivery in rural communities by supporting investments in clinical infrastructure, workforce development, technology, care coordination, and other system-level improvements. While the program is not specific to HIV, many of its priorities align closely with the capabilities needed to improve HIV prevention, testing, treatment, and long-term care in rural communities.
For organizations serving people living with HIV, hepatitis C, and other infectious diseases, understanding this funding landscape has become increasingly important. Many of these opportunities can help providers expand services, strengthen financial sustainability, and improve access for communities that have historically faced the greatest barriers to care.
To help organizations navigate this rapidly evolving landscape, we have developed a state-by-state Rural Health Transformation Program tracker. The resource summarizes each state's RHTP allocation, highlights current and upcoming funding opportunities, identifies key engagement opportunities such as webinars and stakeholder meetings, and links directly to official state program pages. Because funding announcements are rolling out on different timelines across the country, we will continue updating the tracker as new opportunities become available.
The lesson from Austin was never simply about one outbreak. It demonstrated how quickly infectious diseases can spread when prevention, primary care, and public health infrastructure are allowed to weaken. Today's rural communities have an opportunity to move in a different direction. By investing in the systems that expand access to care before the next crisis emerges, they can improve health outcomes for their communities and reduce the conditions that allow outbreaks to occur in the first place.
