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Risk Factors

Race and ethnicity are not, by themselves, risk factors for HIV infection. However, American Indian/Alaska Natives (AI/AN) may face additional challenges associated with risk for HIV infection, including the following.

Sexual Risk Factors
The presence of a sexually transmitted disease can increase the chance of contracting or spreading HIV [3]. High rates of Chlamydia trachomatis infection, gonorrhea, and syphilis among AI/AN suggest that the sexual behaviors that facilitate the spread of HIV are relatively common among AI/AN. According to 2005 surveillance data by race/ethnicity, the 2nd highest rates of gonorrhea and Chlamydia trachomatis infection were those for AI/AN. The 3rd highest rate of syphilis was that for AI/AN [4, 5].

Substance Use
People who casually or habitually use illicit drugs or who abuse alcohol are more likely to engage in risky behaviors such as unprotected sex when under the influence of drugs or alcohol [6]. Results of the 2005 National Survey on Drug Use and Health indicate that the rate of current illicit drug use was higher among AI/AN (12.8%) than among persons of other races or ethnicities [7].

Cultural Diversity
To be effective, HIV/AIDS prevention interventions must be tailored to specific audiences. The American Indian and Alaska Native population makes up 564 federally recognized tribes plus at least 50 state-recognized tribes [8]. Because each tribe has its own culture, beliefs, and practices and these tribes may be subdivided into language groups, it can be challenging to create programs for each group. Therefore, prevention programs that can be adapted to individual tribal cultures and beliefs are critically important. Current programs emphasize traditional teachings and the importance of the community.

Socioeconomic Issues
Issues related to poverty (for example, lower levels of education and poorer access to health care) may directly or indirectly increase the risk for HIV infection [9]. Socioeconomic factors, such as poverty, coexist with epidemiologic risk factors for HIV infection in American Indian and Alaska Native communities. During 2002–2004, approximately one quarter (24.3%) of AI/AN - about twice the national average (12.4%) - were living in poverty [10]. The proportion of the American Indian and Alaska Native population with a high school diploma (66%) in 1990 was less than the national average (75%) [11].

Life expectancy for AI/AN is shorter than that for persons of other races/ethnicities in the United States; the rates of many diseases, including diabetes, tuberculosis, and alcoholism, are higher; and access to health care is poorer [12, 13]. These indicators demonstrate the vulnerability of AI/AN to additional health stress, including HIV infection.

HIV Testing Issues
Access to HIV testing and issues concerning confidentiality are important for many AI/AN. For example, at the time of AIDS diagnosis, more AI/AN, compared with persons of other races/ethnicities, resided in rural areas [14].

Those who live in rural areas may be less likely to be tested for HIV because of limited access to testing. Also, AI/AN may be less likely to seek testing because of concerns about confidentiality in close-knit communities, where someone who seeks testing is likely to encounter a friend, a relative, or an acquaintance at the local health care facility.

During 1997–2000, 50.5% of AI/AN who responded to the Behavioral Risk Factor Surveillance System survey reported that they had never been tested for HIV. This percentage was higher in the southwestern United States, where 58.1% of the AI/AN reported never having been tested [15].

Data Limitations
Current data regarding HIV infection and AIDS among AI/AN have limitations.

  • Incomplete surveillance data. Not all states with large American Indian and Alaska Native populations have been conducting HIV surveillance. For example, California began HIV surveillance only during the past few years and thus is not included in these data.
  • Racial misclassification and underreporting. Even though the numbers of diagnoses for AI/AN are relatively low, these numbers may be affected by racial misclassification. Studies in Alaska and Los Angeles have shown that the degree of misclassification differs geographically. In Alaska, 3% of AI/AN with HIV/AIDS were misclassified as being of another race; in Los Angeles, 56% of AI/AN with AIDS were racially misclassified [16, 17].

In the United States, the annual number of new HIV infections declined from a peak of more than 150,000 during the mid-1980s and stabilized since the late 1990s at approximately 40,000. Minority races/ethnicities are disproportionately affected by the HIV epidemic. To further reduce the incidence of HIV infection, CDC announced Advancing HIV Prevention (AHP) Exit Disclaimer: You Are Leaving  in 2003. This initiative comprised 4 strategies: making HIV testing a routine part of medical care, implementing new models for diagnosing HIV infections outside medical settings, preventing new infections by working with HIV-infected persons and their partners, and further decreasing perinatal HIV transmission.

Through AHP, CDC conducted demonstration projects in American Indian and Alaska Native communities to examine ways to make voluntary HIV testing a routine part of medical care and to implement new models for diagnosing HIV infections outside medical settings. Preliminary data show that through these projects, over 2,000 AI/AN were tested for HIV. Demonstration projects were conducted at the following sites:

  • Salt Lake City, Utah, where a community-based organization (CBO) partnered with the Indian Walk-in Center to offer routine testing—including rapid testing at some sites—to 5 tribal entities and 11 reservations.
  • Phoenix, Arizona, where a CBO conducted routine HIV testing in nontraditional settings (e.g., health fairs, powwows) through local outreach.
  • Sault Ste. Marie, Michigan, where the Sault Ste. Marie Tribe and the Chippewa Indian Sault Tribe Health Center conducted routine HIV testing for clients aged 17 to 49. Rapid testing was conducted simultaneously at 1 main health center and 4 satellite clinics as well as an urgent care clinic.

CDC, through the Minority AIDS Initiative, supports efforts to reduce the health disparities experienced in communities of persons of minority races/ethnicities who are at high risk for HIV. These funds are used to address high-priority HIV prevention needs in such communities. The following are some CDC-funded prevention programs that state and local health departments and CBOs provide for AI/AN.

  • Helping tribes develop or expand HIV prevention services and improve services for persons infected with, or affected by, HIV/AIDS
  • Building and strengthening the capacity of tribal organizations and urban Indian health centers throughout the United States to develop effective HIV prevention through intertribal networking and collaboration
  • Providing HIV prevention education in rural Alaska Native communities and implementing an evidence-based intervention, Community PROMISE, in the Yukon-Kuskokwim delta and Maniilaq regions.

Understanding HIV and AIDS Data
AIDS surveillance: Through a uniform system, CDC receives reports of AIDS cases from all US states and territories. Since the beginning of the epidemic, these data have been used to monitor trends because they are representative of all areas. The data are statistically adjusted for reporting delays and for the redistribution of cases initially reported without risk factors. As treatment has become more available, trends in new AIDS diagnoses no longer accurately represent trends in new HIV infections; these data now represent persons who are tested late in the course of HIV infection, who have limited access to care, or in whom treatment has failed.

HIV surveillance: Monitoring trends in the HIV epidemic today requires collecting information on HIV cases that have not progressed to AIDS. Areas with confidential name-based HIV infection reporting requirements use the same uniform system for data collection on HIV cases as for AIDS cases. A total of 33 states (Alabama, Alaska, Arizona, Arkansas, Colorado, Florida, Idaho, Indiana, Iowa, Kansas, Louisiana, Michigan, Minnesota, Mississippi, Missouri, Nebraska, Nevada, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, West Virginia, Wisconsin, and Wyoming) have collected these data for at least 5 years, providing sufficient data to monitor HIV trends and to estimate risk behaviors for HIV infection.

HIV/AIDS: This term is used to refer to 3 categories of diagnoses collectively: (1) a diagnosis of HIV infection (not AIDS), (2) a diagnosis of HIV infection and a later diagnosis of AIDS, and (3) concurrent diagnoses of HIV infection and AIDS.

For more information, refer to the "HIV Among American Indians and Alaska Natives" Fact Sheet [PDF - 333 KB]