According to the 2000 census, the AI/AN population represents less than 2% of the total population. Their small numbers mean that they are often not well represented in most national surveys; thus we know surprisingly little about this population. Their diversity contributes additional complexity to understanding their communities and characteristics. AI/ANs comprise 562 federally recognized tribes and Alaska Native Villages. Estimates derived from national surveys regarding AI/ANs can be misleading because this diversity is rarely accounted for within sample design or analyses. With this inherent weakness in most national or sample surveys, census data provide one of the main sources of information on this group. The statistics are striking. About 12% of the national population lives below the poverty line, compared to 28% of all AI/ANs and 36% of AI/AN children living on reservations. Unemployment rates are above 10% for most tribes;⁴,** households are usually very crowded; and educational achievement lags behind that of other Americans, with only 10% of all reservation-resident AIs holding a bachelor’s degree or higher, compared with 24% in the U.S. general population.⁵ AI/ANs also endure elevated levels of mortality and morbidity. Age-adjusted mortality rates, for example, show that AI/ANs are over 7 times more likely to die from alcoholism compared to the U.S. general population, 1.5 times as likely to die from firearm wounds, almost twice as likely to experience a homicidal death, and over 3 times as likely to die in a car accident. AI/ANs are also at increased risk of suicide, with age-adjusted suicide rates for AI/ANs estimated to be 72% higher than for the general population.⁶ As yet, we know little about how this challenging environment may shape the relationship between HIV and AIDS status and psychiatric disorder. These statistics also do not reveal the strengths of family and community life. AI/ANs, on and off the reservation, often have strong ties to extended family, tribal communities, and cultural traditions, ceremonies, and beliefs. Distant relatives or friends may be referred to as “aunties” or “grandfathers”; cousins may be referred to as “brothers” or “sisters.” Honoring ceremonies, powwows, and funerals bring even the most urbanized AI/ANs together. Such ties and community strength may act as protective factors in risk behavior associated with HIV transmission and in mental illness.

The number of AIDS cases among AI/ANs have undergone over a 1,000% increase from 1990 (223 cases) to 2003 (3,026 cases). AI/ANs experience a faster progression, from HIV infection to AIDS than any other racial group in the United States. In 2001, 48% of AI/ANs diagnosed with HIV infection were subsequently diagnosed with AIDS within 12 months, compared to 40% for the general population. They also experience one of the lowest survival rates after an AIDS diagnosis is made. Among those with AIDS, AI/ANs are slightly younger than the national population on average. Among AI/ANs diagnosed with AIDS, youth aged 13 to 24 years make up 6% of all cases, cumulatively, compared to 4% in the general population.² The percent of AI/ANs diagnosed with AIDS who were women or girls ranged between 22% and 31% from 1999 to 2002, with no discernible trend. The current level, 26% in 2002, is second only to that in Blacks, in which women and girls comprise 34% of all diagnosed cases.²

These HIV infection and AIDS statistics for AI/ANs are even more concerning because they are likely to be underestimated due to racial or ethnic misclassification.⁷ Further, national
trends tend to dilute local experiences of HIV disease and AIDS. AI/ANs are residentially concentrated in a relatively limited geographic area—about 60% of the total AI/AN population resides in about 11 states.⁵,*** Finally, many of those states, such as Alaska, California, and New York, do not require confidential name-based HIV infection reporting; thus, we know very little about HIV status for substantial sectors of the AI/AN population. Indeed, we did not reference HIV trends because of the likely biases they contain because reporting policies are not uniform across states.⁵,†

The predominant mode of transmission has been men having sex with men (MSM) sexual contact, comprising 60% of transmission cumulatively, slightly more than 54% of the national general population. Although many tribes traditionally accepted and even revered those people who were “two spirited” or winkte, the influence of mainstream American culture has resulted in the stigmatization of those members of an AI/AN community who are gay, lesbian, bisexual, or transgender (GLBT); this also puts them at increased risk because they are more likely to engage in clandestine activities. Little research exists on the complexity of GLBT issues in AI/AN communities, but anecdotal evidence suggests that such persons may engage in homosexual behavior only when under the influence of drugs or alcohol, because their dis- inhibiting influence may allow them, first, to pursue such activities and, second, because they may not be held accountable, socially, for such actions if intoxicated. Additionally, GLBT AI/ANs may pursue differential identity strategies, depending on where they are. That is, in reservation communities, they may present themselves as heterosexual and engage in heterosexual activities there. When they travel to (or live in) urban communities, they may see themselves as GLBT individuals and engage in different sexual activity. This shifting identification likely increases stress and anxiety, which in turn may be linked to increases in risk taking. It is also likely to increase risk exposure to HIV for persons residing in reservations and who are sexually active with persons who do not disclose their own sexual identity or possible risk of HIV infection.

Although AIDS incidence reports had indicated a shift in proportion from transmission via MSM to transmission via heterosexual contact and injection drug use (IDU), data for 2001 and 2002 show that concrete trends are not yet established. From 1999 to 2002, MSM transmission levels have begun to increase again since reaching a low of 47% in 2000, rising to a high of 55% in 2002 (which includes MSM and IDU as dual mode of transmission category); levels of IDU transmission rates similarly have varied over that same period, ranging between 33% and 43%; and rates for heterosexual transmission have remained roughly unchanged at about 20%, a level similar to that for Blacks and Hispanics. Of importance, IDU as a mode of transmission is the highest among AI women and girls (43%) compared to women and girls of any other race groups (Whites, 38%; Blacks, 28%; Hispanics, 26%; Asian and Pacific Islanders, 18%).²

Sexual risk taking and substance use are among the main risk factors for AI/AN populations. The prevalence of sexually transmitted infections (STIs), a marker of sexual risk taking, is 2 to 6 times higher among AI/ANs than in the general U.S. population.⁸ According to the National Study of Drug Use and Health (NSDUH),‡ in 2002, about 60% of AI/ANs reported illicit drug use at some point in their lives, compared to 46% nationally.⁹ Related to AI/AN drug use, the elevated levels of diabetes among AI/ANs, and the commensurate
increase in insulin injections, have resulted in a greater availability of discarded needles, which are then used for illicit injection drugs. According to the NSDUH of 2001,⁹ although AI/ANs reported less lifetime alcohol use (by 10 points) than the general population, about 30% reported binge or heavy drinking, compared to 26% nationally. Thus, alcohol, like drug use, may be a factor for some AI/ANs, but will likely vary considerably in whether it plays a role in risk taking for or coping with HIV disease or AIDS.

Location may also be a factor in risk. AI/ANs are more likely to reside in rural areas, often remote reservation areas or villages, compared to other race groups. Although the relative isolation of many of these communities may appear to afford some protection, in fact, in most cases, these communities are not so isolated. AI/ANs travel back and forth between urban areas and reservations to attend school or work or to participate in cultural and family events. This pattern of urban–rural circulation, coupled with high levels of STIs and substance use, places even remote rural communities at risk. Further, persons living in remote areas are less likely to have access to appropriate testing, counseling, and treatment services. A number of other additional factors may also foster HIV and AIDS transmission for this population. The small and often tightly knit communities in which AI/ANs live mean that stigma, fear of a breach of confidentiality in medical services, and wide-ranging taboos and proscriptions on sexual behavior, including same-sex sexual behavior may increase risk. Sexual networks also can be extensive in AI/AN communities, as evidenced by a recent well-publicized incident of HIV exposure. The often long distances to health care facilities may also make prevention, testing, and care challenging. As we note later in the chapter, many facilities of the Indian Health Service (IHS), estimated to serve approximately 60% of the eligible AI/AN population, are inadequately staffed and trained and they often lack appropriate medications, especially for HIV disease and AIDS, providing further disincentive to seek testing or treatment. In urban areas, while HIV/AIDS- related services may be more available, IHS services are not. About 60% of AI/ANs live in urban areas, but only three urban IHS-funded clinics exist, and only 1% of the total IHS budget is designated for urban services. Many AI/ANs speak languages other than English, and even when English is spoken, terms and phrasing may differ between local use and medical provider use. Moreover, some AI/AN groups adhere to forms of communication that may increase social distance to providers, such as avoiding eye contact, prolonged periods of silence, or a soft handshake. Finally, it is worth noting that some traditions and ceremonies involve skin piercing or tattooing. Absent sterile implements, these practices may also elevate risk of HIV transmission.