- HIV affects AI/AN in ways that are not always obvious because of their small population sizes.
- Of all races/ethnicities, AI/AN had the highest percentages of diagnosed HIV infections due to injection drug use.
- AI/AN face HIV prevention challenges, including poverty, high rates of STIs, and stigma.
HIV is a public health issue among the approximately 5.2 million American Indians and Alaska Natives (AI/AN), who represent about 1.7%1 of the U.S. population. Compared with other racial/ethnic groups, AI/AN ranked fifth in estimated rates of HIV infection diagnoses in 2013, with lower rates than in blacks/African Americans, Hispanics/Latinos,2 Native Hawaiians/Other Pacific Islanders, and people reporting multiple races, but higher rates than in Asians and whites.
Overall, the effect of HIV infection on AI/AN is proportional to their U.S. population size. However, within the overall statistics of new HIV infections and diagnoses, certain measures are disproportionate in this population group relative to other races/ethnicities.
New HIV Infections3
- In 2010, fewer than 1% (210) of the estimated 47,500 new HIV infections in the United States were among AI/AN.
HIV and AIDS Diagnoses4 and Deaths
- AI/AN men accounted for 78% (169) and AI/AN women accounted for 22% (49) of the estimated 218 AI/AN diagnosed with HIV infection in the United States in 2013.
- Of the estimated 169 HIV diagnoses among AI/AN men in 2013, most (71%; 120) were attributed to male-to-male sexual contact.
- Of the estimated 49 HIV diagnoses among AI/AN women in 2013, the majority (69%, 34) were attributed to heterosexual contact.
- In the United States in 2013, both male and female AI/AN had the highest percent of estimated diagnoses of HIV infection attributed to injection drug use, compared with all races/ethnicities. Among men, 13% (22) of new HIV diagnoses were attributed to injection drug use and 6% (10) were attributed to both male-to-male sex and injection drug use. Among women 29% (14) of new HIV diagnoses were attributed to injection drug use.
- In 2013, an estimated 104 AI/AN were diagnosed with AIDS, a number that has remained relatively stable since 2009.
- By the end of 2012, an estimated 1,867 AI/AN with AIDS had died in the United States.
Estimated Diagnoses of HIV Infection Among Adult and Adolescent American Indians/Alaska Natives by Transmission Category and Sex, 2011 -- United States
†Male-to-male sexual contact. ‡Injection drug use §Male-to-male sexual contact and injection drug use.
The terms male-to-male sexual contact (MSM) and male-to-male sexual contact and injection drug use (MSM/IDU) are used in CDC surveillance systems. They indicate the behaviors that transmit HIV infection, not how individuals self-identify in terms of their sexuality.
Why Are American Indians and Alaska Natives Affected by HIV?
Race and ethnicity alone are not risk factors for HIV infection. However, AI/AN may face challenges associated with risk for HIV.
- Lack of awareness of HIV status. Overall, approximately one in 7 (14%) adults and adolescents living with HIV infection in the United States at the end of 2011 were unaware of their HIV infection. Of the 3,700 American Indians and Alaska Natives estimated to be living with HIV in 2011, 18.9% (700) are estimated to be undiagnosed.
- Sexually transmitted diseases (STDs). AI/AN have the second highest rates of chlamydia and gonorrhea and the fourth highest rate of syphilis among all racial/ethnic groups. STDs increase the susceptibility to HIV infection.
- 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 and can be subdivided into language groups, it can be challenging to create culturally appropriate prevention programs for each group.
- 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 and consists of direct services delivered by the IHS, tribally operated health care programs, and urban Indian health care services and resource centers. However, because of confidentiality and quality-of-care concerns and a general distrust of the U.S. government, some AI/AN may avoid IHS.
- Alcohol and illicit drug use. Although alcohol and substance use do not cause HIV infection, they can reduce inhibitions and impair judgment and lead to behaviors that increase the risk of HIV. Injection drug use directly increases the risk of HIV through contaminated syringes and works. Compared with other racial/ethnic groups, AI/AN tend to use alcohol and drugs at a younger age, use them more often and in higher quantities, and experience more negative consequences from them.
- 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 AI/AN-targeted services.
What CDC Is Doing
The Centers for Disease Control and Prevention (CDC) and its partners are pursuing a High-Impact Prevention approach to advance the goals of the National HIV/AIDS Strategy (NHAS),maximize the effectiveness of current HIV prevention methods, and improve surveillance 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 intervention approaches that reach those at greatest risk for HIV and AIDS, 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 for AI/AN.
- Ensuring that capacity-building assistance providers incorporate cultural competency, and 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.
- Collaborated 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.
- Launched the Act Against AIDS (AAA) initiative, including Let's Stop HIV Together, which addresses stigma and raises awareness of HIV among people of all races.
In addition, the Office for State, Tribal, Local, and Territorial Support (OSTLTS) serves as the primary link between CDC, the Agency for Toxic Substance and Disease Registry, and tribal governments. OSTLTS' 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.
- U.S. Census Bureau. Facts for Features, American Indian and Alaska Native Heritage Month, 2014. Accessed March 3, 2015.
- CDC. Diagnoses of HIV infection and AIDS in the United States and dependent areas, 2013. HIV Surveillance Report 2014;25. Accessed March 3, 2015.
- CDC. Estimated HIV incidence among adults and adolescents in the United States, 2007-2010. HIV Surveillance Supplemental Report 2012;17(4). Accessed March 11, 2014.
- CDC. Monitoring Selected National HIV Prevention and Care Objectives by Using HIV Surveillance Data -- United States and 6 Dependent Areas -- 2012. Accessed March 3, 2015.
- CDC. Sexually Transmitted Disease Surveillance 2013. Atlanta: U.S. Department of Health and Human Services; 2014. Accessed March 3, 2015.
- 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.
- Indian entities recognized and eligible to receive services from the Bureau of Indian Affairs. Fed Regist 2012;77(155):47868. Accessed March 3, 2015.
- 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 March 14, 2014.
- 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. Accessed March 3, 2015.
- Bertolli J, Lee LM, Sullivan PS, AI/AN 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, U.S., 1984-2000. Public Health Rep 2007;122(3):382-94.
- Oetting ER, Beauvais F. Epidemiology and correlates of alcohol use among Indian adolescents living on reservations. In: Alcohol Use Among U.S. Ethnic Minorities, NIAAA research monograph No. 18. Rockville, MD: U.S. Public Health Service; 1989:239-67.
- CDC. High-Impact HIV Prevention: CDC's Approach to Reducing HIV Infections in the United States. Accessed February 28, 2013.
- CDC. Report: Improving HIV Surveillance Among American Indians and Alaska Natives in the United States. January 2013. Accessed March 3, 2015.
CDC HIV Website
CDC Act Against AIDS Campaign
- Census population estimates for AI/AN include those reporting Hispanic ethnicity or one or more races.
- Hispanics/Latinos can be of any race.
- New HIV infections refer to HIV incidence, or the number of people who are newly infected with HIV, whether or not they are aware of their infection.
- HIV and AIDS diagnoses refer to the number of people diagnosed with HIV infection (regardless of stage of disease) and the number of people diagnosed with AIDS, respectively, during a given time period. The terms do not indicate when they were infected.