WASHINGTON, DC—Getting patients with HIV into care is key to helping them prolong their life. At the Phoenix Indian Medical Center (PIMC) HIV Center of Excellence, medical personnel are hoping that with the right care and prevention efforts, they can help reduce HIV transmission among the American Indian and Alaska Native (AI/AN) population they serve. “We try to treat the patient holistically in a chronic care model because with the efficacy of antiretroviral therapy it really is a chronic disease,” said Marie Russell, MD, MPH, associate director for the Centers of Excellence at PIMC.

Even though the numbers of HIV and AIDS diagnoses for the AI/AN population represent less than 1% of the total number of HIV/AIDS cases reported to CDC, when population size is taken into account, they ranked third in 2005 in rates of HIV/AIDS diagnosis.

While race and ethnicity are not in themselves risk factors for HIV, the AI/AN population does face a number of challenges that are associated with HIV infection. For example, they have a high rate of sexually transmitted diseases, and the presence of a sexually transmitted disease can increase the chance of contracting or spreading HIV.

Other risk factors for HIV include substance abuse and alcoholism. Persons who are under the influence of drugs or alcohol are more likely to engage in risky behaviors, such as unprotected sex. AI/AN have high rates of illicit drug use.

Socioeconomic factors also play a role, according to Russell. She pointed out that there are high poverty rates among the AI/AN population and that only about 66% of the AI/AN population have high school diplomas.

PIMC Offers Care

The PIMC HIV Center of Excellence is staffed by a physician who is certified in HIV medicine, an HIV certified pharmacist, and two case managers who actively case manage the population.

Russell said that the team has been successful in helping patients adhere to their treatment of antiretrovirals. In FY 2009, 90% of the patients treated at the center on antiretrovirals were adherent to their treatment when measured by viral load. “That really is credit to our team who follows all of the standards of care. The antiretroviral therapy is the only thing that has been shown in [the] HIV population to prolong their [lives], so compliance is a huge issue.”

One of the strengths of the program, according Russell, is that it is culturally geared towards the population it serves. ’In order to effectively treat HIV it needs to be culturally appropriate. A lot of our folks just feel more comfortable seeking care in an Indian Health Service facility.”

Testing individuals for HIV is key in helping prevent the spread of the virus. In recent years CDC has recommended that voluntary HIV screening be conducted as part of routine medical care for all patients ages 13 to 64. IHS promotes these recommendations among its medical personnel. While informed consent for HIV testing is required, adults and adolescents do not require specific or separate written consent for HIV testing. 

Russell said that by making HIV testing a part of routine medical care, it decreases the stigma associated with testing and at PIMC they are encouraging physicians to follow these guidelines.

Moving forward, PIMC, along with Alaska Native Medical Center and Gallup Indian Medical Center, is expanding its reach through a national HIV telemedicine network. These medical centers have specialized care for HIV patients and the telemedicine network is designed to allow IHS providers from all over the country to access the HIV expertise at these medical centers for HIV case consultation. In rural areas where HIV expertise may not be so robust, it is hoped that the telemedicine network will serve as a resource for IHS providers caring for HIV patients. ’Our hope is to have any IHS/tribal site that cares for HIV positive patients participate in the network for case consultation,” said Russell.

Challenges in Curbing the Spread of HIV

Resources are one of the major challenges in caring for HIV patients in IHS. IHS does not have a separate line item budget for HIV/AIDS treatment and prevention services. The primary source of funding for medical services is the Hospitals and Health Clinics budget, according to IHS. The Minority AIDS Initiative funds a select number of projects within IHS dealing with training,
epidemiology, technology, and telemedicine. 

Another challenge is that while PIMC has antiretroviral medications as part of its drug formulary, not every IHS facility has these medications on their formulary.

In general, HIV prevention is a challenge in the US. Among AI/AN, prevention can be especially challenging because there are more than 560 federally recognized tribes and each one has its own culture, beliefs, and practices, according to Russell. This means that one type of prevention message does not necessarily fit every tribe. “It is really necessary to provide a set of tools that each locality can tailor to fit their own tribal beliefs and culture system. I think that that is quite challenging in regards to prevention, because something that may be acceptable for one tribe may not be acceptable for another.”

CDC also cites that individuals who live in rural areas with limited access to testing, as many AI/AN do, may be less likely to be tested. In addition, American Indians and Alaska Natives 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 healthcare facility.

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