HIV is a critical 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. AI/AN represented less than 1% of estimated new HIV infections in 2010. When compared with other racial/ethnic groups, AI/AN ranked fifth in estimated rates of HIV infection diagnoses in 2011, with lower rates than blacks/African Americans, Hispanics/Latinos, Native Hawaiians/Other Pacific Islanders, and people reporting multiple races, but higher rates than Asians and whites.

The Numbers

New HIV Infections²

• In 2010, AI/AN accounted for less than 1% (210) of the estimated 47,500 new HIV infections in the United States.

HIV and AIDS Diagnoses³ and Deaths

• AI/AN men accounted for 76% (161) and AI/AN women accounted for 24% (51) of the estimated 212 AI/AN diagnosed with HIV infection in 2011.
• Seventy five percent (120) of the estimated 161 HIV diagnoses among AI/AN men in 2011 were attributed to male-to-male sexual contact. Sixty-three percent (32) of the estimated 51 HIV diagnoses among AI/AN women were attributed to heterosexual contact.
• In 2011, an estimated 146 AI/AN were diagnosed with AIDS, a number that has remained relatively stable since 2008.
• By the end of 2010, an estimated 1,945 AI/AN with an AIDS diagnosis had died in the United States. In 2010, HIV infection was the ninth leading cause of death among AI/AN men and women aged 25 to 34.

Estimated Diagnoses of HIV Infection Among Adult and Adolescent American Indians/Alaska Natives by Transmission Category and Gender, United States, 2011*

* Because of rounding, the percentages do not equal 100%. Because the estimated total (N) was calculated independently of the values of the subpopulation, the subpopulation values do not sum to the total.

Prevention Challenges

Race and ethnicity are not, by themselves, risk factors for HIV infection. However, AI/AN are likely to face challenges associated with risk for HIV infection.

• Sexually transmitted diseases (STIs). AI/AN have higher rates of chlamydia, gonorrhea, and syphilis than whites and Hispanics/Latinos and are second only to blacks/African Americans, who have the highest rates for all three STIs. STIs increase the susceptibility to HIV infection.
• AI/AN gay and bisexual or "two-spirit" men may face culturally based stigma and confidentiality issues that may limit opportunities for education and HIV testing, especially among those who live in rural communities or on reservations.
• Cultural diversity. There are 566 federally recognized AI/AN tribes, whose members speak some 200 languages. 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 culturally appropriate prevention programs for each group. Tribal and cultural differences regarding gender and sexuality within the AI/AN community must be considered in developing culturally appropriate prevention strategies.
• Socioeconomic issues. Poverty, including limited access to high-quality health care, housing, and HIV prevention education, directly and indirectly increase the risk for HIV infection and affect 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 issues and a general distrust toward the U.S. government, some AI/AN may avoid IHS.
• Alcohol and illicit drug use. Substance use can lead to sexual behaviors that increase the risk of HIV infection. Although alcohol and substance abuse does not cause HIV infection, it is an associated risk factor because of its ability to reduce inhibitions and impair judgment. 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.
• Lack of awareness of HIV status. Overall, approximately one in five (18%) U.S. adults and adolescents living with HIV infection at the end of 2009 were unaware of their HIV infection. However, a greater percentage of adult and adolescent AI/AN (25%) were estimated to have undiagnosed HIV infection at the end of 2009. This translates to approximately 1,100 people in the AI/AN community living with undiagnosed HIV infection at the end of 2009.
• 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

• Support and technical assistance to health departments and community-based organizations to deliver effective prevention interventions for AI/AN, such as Community PROMISE and Commitment to Action for 7th Generation Awareness & Education: HIV/AIDS Prevention Project (CA7AE:HAPP), which coordinates National Native HIV/AIDS Awareness Day
• Phases of the Act Against AIDS (AAA) campaign, including Greater Than AIDS, which focuses on gay and bisexual men of all races; and Let's Stop HIV Together, which addresses stigma and raises awareness.
• The Care and Prevention in the United States (CAPUS) Demonstration Project that supports increased testing and optimizes linkage to, retention in, and re-engagement with care and prevention services for newly diagnosed and previously diagnosed racial and ethnic minorities with HIV.
• In January 2012, CDC began the Comprehensive Human Immunodeficiency Virus (HIV) Prevention Programs for Health Departments (Funding Opportunity Announcement [FOA] PS 12-1201) a 5-year, $339 million HIV prevention FOA for health departments in states, territories, and select cities including those serving AI/AN clients.
• 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.

References

1. Census population estimates for AI/AN include those reporting Hispanic ethnicity or one or more races.
2. New HIV infections refer to HIV incidence, or the number of people who are newly infected with HIV.
3. HIV and AIDS diagnoses refer to the number of people diagnosed with HIV infection and the number of people diagnosed with AIDS, respectively, during a given time period. The terms do not indicate when they were infected.