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HIV Among American Indians and Alaska Natives

Fast Facts

  • HIV affects American Indians and Alaska Natives (AI/AN) in ways that are not always obvious because of their small population sizes.
  • Over the last decade, new diagnoses increased 63% among AI/AN gay and bisexual men.
  • AI/AN face HIV prevention challenges, including poverty, high rates of STIs, and stigma.

	photo of an American Indian coupleHIV is a public health issue among American Indians and Alaska Natives (AI/AN), who represent about 1.2%a of the US population. Compared with other racial/ethnic groups, AI/AN ranked fifth in estimated rates of new HIV diagnoses in 2014, with lower rates than blacks/African Americans, Hispanics/Latinos,b Native Hawaiians/Other Pacific Islanders, and people reporting multiple races, but higher rates than Asians and whites.

The Numbers

Overall, the estimated number of new HIV diagnoses among AI/AN is proportional to their population size. However, certain measures of new HIV diagnoses reveal disproportionate impact among AI/AN when compared to other races/ethnicities.

HIV and AIDS Diagnosesc

  • Of the estimated 44,073 new HIV diagnoses in the United States in 2014, 1% (222) were among AI/AN. Of those, 77% were men and 22% were women.
  • Of the estimated 170 HIV diagnoses among AI/AN men in 2014, most (84%; 142) were among gay and bisexual men.d
  • Most of the estimated 49 HIV diagnoses among AI/AN women in 2014 were attributed to heterosexual contact (73%; 36).
  • From 2005 to 2014, the number of new HIV diagnoses increased 19% among AI/AN overall and 63% among AI/AN gay and bisexual men.
  • In 2014, an estimated 95 AI/AN were diagnosed with AIDS. Of them, 73% (69) were men and 25% (24) were women.

Estimated New HIV Diagnoses Among Adult and Adolescent AI/AN
in the US by Transmission Category and Sex, 2014
	Pie charts show the estimated new HIV diagnoses among American Indians and Alaska Natives in the United States in 2014, by transmission category and sex. Total diagnoses among males = 170. Male-to-male sexual contact = 142 diagnoses, 84% of all males. Injection drug use (males) = 11 diagnoses, 6% of all males. Heterosexual contact (males) = 10 diagnoses, 6% of all males. Male-to-male sexual contact and injection drug use = 7 diagnoses, 4% of all males. Total diagnoses among females = 49. Heterosexual contact (females) = 36 diagnoses, 73% of all females. Injection drug use (females) = 13 diagnoses, 27% of all females.

† Injection drug use
The terms male-to-male sexual contact and male-to-male sexual contact and injection drug use are used in CDC surveillance systems. They indicate the behaviors that transmit HIV infection, not how indiividuals self-identify in terms of their sexuality.

Source: CDC. Diagnoses of HIV infection in the United States and dependent areas, 2014. HIV Surveillance Report 2015;26.

Living With HIV and Deaths

  • In 2012, 13% of all persons living with HIV in the United States were undiagnosed. Of the 3,800 AI/AN estimated to be living with HIV in 2012, 19% (720) were undiagnosed.
  • Of AI/AN diagnosed with HIV in 2013, 86% were linked to medical care within 3 months.e
  • At the end of 2012, 47% of AI/AN who had been living with diagnosed HIV for at least a year were retained in care (receiving continuous HIV medical care), and 45% had achieved viral suppression.f By comparison, 54% of all people living with HIV in the United States were retained in care, and 50% had achieved viral suppression.
  • During 2013, 53 AI/AN died from HIV or AIDS.

Prevention Challenges

  • Sexually transmitted diseases (STDs). From 2010 to 2014, AI/AN had the second highest rates of chlamydia, gonorrhea, and syphilis among all racial/ethnic groups. Having another STD increases a person’s risk for getting or transmitting HIV.
  • Lack of awareness of HIV status. Almost 1 in 5 AI/AN who were living with HIV in 2012 were unaware of their status. People who do not know they have HIV cannot take advantage of HIV care and treatment to improve their health and reduce the risk of passing HIV to others.
  • Stigma. AI/AN gay and bisexual men may face culturally based stigma and confidentiality concerns that could limit opportunities for education and HIV testing, especially among those who live in rural communities or on reservations.
  • Cultural diversity. There are over 560 federally recognized AI/AN tribes, whose members speak over 170 languages. Because each tribe has its own culture, beliefs, and practices, creating culturally appropriate prevention programs for each group can be challenging.
  • Socioeconomic issues. Poverty, including lack of housing and HIV prevention education, directly and indirectly increases the risk for HIV infection and affects the health of people living with and at risk for HIV infection. Compared with other racial/ethnic groups, AI/AN have higher poverty rates, have completed fewer years of education, are younger, are less likely to be employed, and have lower rates of health insurance coverage.
  • Mistrust of government and its health care facilities. The federally funded Indian Health Service (IHS) provides health care for approximately 2 million AI/AN. However, because of a historic distrust of the US government, some AI/AN may avoid IHS.
  • Alcohol and illicit drug use. Alcohol and substance use can impair judgment and lead to behaviors that increase the risk of HIV. Injection drug use can directly increase the risk of HIV through sharing contaminated needles, syringes, and other equipment. Compared with other racial/ethnic groups, AI/AN tend to use alcohol and drugs at a younger age and use them more often and in higher quantities.
  • Data limitations. Racial misidentification of AI/AN may lead to the undercounting of this population in HIV surveillance systems and may contribute to the underfunding of targeted services for AI/AN.

What CDC Is Doing

CDC and its partners are pursuing a high-impact prevention approach to advance the goals of the National HIV/AIDS Strategy, maximize the effectiveness of current HIV prevention methods, and improve HIV data collection among AI/AN. Activities include:

  • Working with the Indian Health Service (IHS) and tribal leaders of the CDC Tribal Consultation Advisory Committee to discuss methods for developing and implementing scalable, effective prevention approaches that reach those at greatest risk for HIV, including young gay and bisexual AI/AN men.
  • Providing support and technical assistance to health departments and community-based organizations to deliver effective prevention interventions.
  • Ensuring that capacity building assistance providers incorporate cultural competency, linguistics, and educational appropriateness into all services delivered.
  • Providing capacity building assistance directly to the IHS so it can build HIV testing capacity; create We R Native, focusing on sexual identity; and consult on the Red Talon Project, which works to achieve a more coordinated national and Northwest tribal response to STDs/HIV.
  • Collaborating with National Association of State and Territorial AIDS Directors to release an issue brief, Native Gay Men and Two Spirit People: HIV/AIDS and Viral Hepatitis Programs and Services.
  • Raising awareness through the Act Against AIDS campaigns, including
    • Doing It, a new national HIV testing and prevention campaign that encourages all adults to get tested for HIV and know their status;
    • Let’s Stop HIV Together, which raises HIV awareness and fights stigma among all Americans and provides many stories about people living with HIV; and
    • HIV Treatment Works, which highlights how men and women who are living with HIV have overcome barriers. The campaign provides resources and encourages people living with HIV to get in care, stay in care, and live well.  

In addition, the Office for State, Tribal, Local, and Territorial Support (OSTLTS) serves as the primary link between CDC, the Agency for Toxic Substances and Disease Registry, and tribal governments. OSTLTS’s tribal support activities are focused on fulfilling CDC’s supportive role in ensuring that AI/AN communities receive public health services that keep them safe and healthy.

a Percentage of AI/AN reporting only one race.
b Hispanics/Latinos can be of any race.
c HIV and AIDS diagnoses indicate when a person is diagnosed with HIV infection or AIDS, but do not indicate when the person was infected.
d The term gay and bisexual men, referred to as men who have sex with men in CDC surveillance systems, indicates how individuals self-identify in terms of their sexuality, not a behavior that transmits HIV infection.
e In 27 states and the District of Columbia (the areas with complete lab reporting by December 2014).
f A person with a suppressed viral load has a very low level of the virus. That person can stay healthy and has a dramatically reduced risk of transmitting the virus to others.

Bibliography

  1. US Census Bureau. Facts for features, American Indian and Alaska Native heritage month, November 2015. Accessed February 9, 2016.
  2. CDC. Diagnoses of HIV infection in the United States and dependent areas, 2014. HIV Surveillance Report 2015;26. Accessed February 9, 2016.
  3. CDC. High-Impact HIV Prevention: CDC’s approach to reducing HIV infections in the United States. Accessed February 9, 2016.
  4. CDC. Improving HIV Surveillance among American Indians and Alaska Natives in the United States. Accessed February 9, 2016.
  5. CDC. Monitoring selected national HIV prevention and care objectives by using HIV surveillance data—United States and 6 dependent areas—2013. HIV Surveillance Supplemental Report 2015;20(2). Accessed February 9, 2016.
  6. CDC. Sexually transmitted disease surveillance 2014. Accessed February 9, 2016.
  7. Burks DJ, Robbins R, Durtschi JP. American Indian gay, bisexual and two-spirit men: a rapid assessment of HIV/AIDS risk factors, barriers to prevention and culturally-sensitive intervention. Cult Health Sex 2011;13(3):283-98. PubMed Abstract.
  8. Bureau of Indian Affairs. Indian entities recognized and eligible to receive services from the United States Bureau of Indian Affairs. Fed Regist 2012;77(155):47868. Accessed February 9, 2016.
  9. James C, Schwartz K, Berndt J. A profile of American Indians and Alaska Natives and their health coverage. Menlo Park, CA: Henry J. Kaiser Family Foundation; 2009. Accessed February 9, 2016.
  10. Walters KL, Simoni JM, Evans-Campbell T. Substance use among American Indians and Alaska Natives: incorporating culture in an ‘Indigenist’ stress-coping paradigm. Public Health Rep 2002;117(1):s104-17. PubMed Abstract.
  11. Bertolli J, Lee LM, Sullivan PS, American Indian/Alaska Native Race/Ethnicity Data Validation Workgroup. Racial misidentification of American Indians/Alaska Natives in the HIV/AIDS reporting systems of five states and one urban health jurisdiction, US, 1984–2000. Public Health Rep 2007;122(3):382-94. PubMed Abstract.
  12. CDC. Deaths: final data for 2013. National Vital Statistics Reports 2016; 64(2). Accessed February 9, 2016.
  13. CDC. Trends in U.S. HIV diagnoses, 2005-2014. Accessed February 9, 2016.

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