Special Projects of National Significance
2005 Report to CARE Act Grantees

American Indian/Alaska Native Initiative

American Indian and Alaska Native Initiative

Background

By the end of 2000, the CDC had received reports of 2,337 AIDS cases among American Indians and Alaska Natives (AI/AN) in the United States and its territories, about a 25 percent increase over the number of cases reported through 1997. The distribution of reported cases along gender and exposure categories among AI/AN was similar to the distribution observed among other racial and ethnic groups. However, studies indicate higher rates of co-morbidities for HIV such as STIs, mental illness (particularly depression), and chemical dependency, including alcoholism, in the AI/AN communities. Often these co-morbidities are linked to one another and facilitate exposure to as well as progression of HIV disease. Moreover, high rates of urban migration, illiteracy, unemployment and poverty among American Indians contribute to inadequate access to or use of health care. Given the health and social problems experienced by American Indians, providing high-quality HIV care is potentially more challenging in AI/AN communities than in the general population.

In June 2001, the HRSA HIV/AIDS Bureau convened a focus group of leaders in the field of HIV services and the AI/AN community. This group identified the need for services integration and cultural competency as the priority for HIV services for AI/AN communities. Further, initiatives that have sought to integrate HIV care, substance abuse treatment, and mental health treatment and link them to primary care have been shown to decrease morbidity and mortality for all three health issues. The National Native American AIDS Prevention Center identified the following needs (among others) for HIV services:

· The development of culturally-specific HIV education and prevention programs acceptable to local AI/AN communities.

· The involvement of AI/AN organizations in providing culturally competent case management services.

· The involvement of HIV-positive American Indians and Alaska Natives in leadership and decision making.

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· The development of protocols to maintain confidentiality within sparsely populated, rural, tightly-knit communities.

· The provision of opportunities to participate in traditional healing and spiritual ceremonies in addition to Western medicine and pharmaceutical products.

· Overcoming poverty-related issues such as access to pharmaceuticals.

· Creating efficient, integrated networks of referrals and services.

The SPNS AI/AN Initiative was developed to address these needs.

The American Indian / Alaska Native Initiative

The American Indian/Alaska Native Initiative is designed to integrate substance abuse and mental health services with HIV primary health care for American Indian and Alaska Native communities. Six demonstration projects and a technical assistance center comprise this five-year initiative, which began in October 2002 and ends in September 2007. Since AI/AN agencies operate under a Federal policy that promotes self determination for American Indian and Alaska Native peoples, the technical assistance center respects the interests of AI/AN projects to develop culturally appropriate solutions to community, tribal, and village issues and encourages solutions to come from the local level. The role of the center is to provide technical assistance to the six HIV/AIDS care demonstration projects for their local evaluation efforts, to assess local evaluation capabilities, and to disseminate the findings of the initiative.

During the first year of the initiative, time was spent refining the local evaluation and proposed interventions. This included formalizing a logic model and client flow chart delineating how HIV counseling and testing, appropriate access to HIV care, and HIV prevention can be integrated and provided to an AI/AN population already receiving services for HIV infection and/or related co-morbidities of STI's, substance abuse and mental health issues. The aforementioned materials served as the basis for developing IRB protocols and in designing a model based on the distinct cultural values and beliefs of the grantees' target population. Ongoing technical assistance is provided to grantees as they enter the implementation phase and begin data collection and evaluation activities. Various products that will be developed from this initiative include, but are not limited to, a report detailing the challenges of implementing multi-site model evaluation projects across the country, a book entitled, `Healing and Mental Health For Native Americans: Speaking in Red', and other reports and dissemination articles from the projects' local evaluation findings.

The target of this initiative includes American Indian and Alaska Natives who are HIV-positive or at risk for HIV infection with co-morbidities of substance abuse (including alcohol), sexually transmitted infections and/or mental illness.

While each project has specific goals and strategies, the overarching theme of this initiative is to integrate an array of services for HIV-positive or at risk American Indian and Alaska Natives, particularly those with co-morbidities as described above, to ultimately improve health of those targeted and prevent the continued spread of HIV within their communities.

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Na'Nizhoozhi Center, Inc (Gallup, NM)

Integrating HIV, Substance Abuse, and Mental Health Services at the Navajo Nation: A Project of the Four Corners American Indian Circle of Services Collaborative

Target Population: American Indian (primarily Navajo) substance users either at high risk for HIV infection because of sexual behaviors or American Indians already living with HIV infection

Goal: To screen persons at risk, to enhance services for HIV-positive clients (to include substance and mental health) and to reduce new HIV infection

Strategies: 1. A network of community agencies identified as experts in the area of substance abuse and mental health, a partnership named the Four Corner Collaborative or 4CC; 2. Train health care providers in case management, screening, counseling, and HIV testing

Evaluation: The project will complete comprehensive process and outcome evaluation via a partnership with the Public Health Program at the University of New Mexico

Contact Information:

Kevin Foley, PhD, Project Director
2205 East Boyd
Gallup, NM 87301
Phone: 505-722-2177

The Healing Lodge, Native American Interfaith Ministries (Pembrook, NC)

Southeastern NC American Indian HIV/AIDS Project

Target Population: American Indians residing in Robeson County, NC, who have or are at high risk of having HIV

Goal: 1. Increase accurate knowledge in the community about HIV/AIDS; 2. Increase HIV testing within the target population; 3. Improve service infrastructure and increase the capacity of the community to focus on HIV/AIDS intervention and services; 4. Decrease the amount of time from HIV diagnosis to engagement in treatment; 5. Improve the ability of the community to provide culturally competent health interventions and services

Strategies: 1. Develop a coordinated network/hub of culturally-based services to include counseling, testing, and referral services (CTRS), a Healing Lodge, and local religious ministries conducted by lay and clergy leaders; 2. Outreach, education, and dissemination activities to bring new participants into the Healing Lodge and help link them with necessary services; 3. Faith-based training of ministers and lay leaders

Evaluation: Formative and summative evaluation will be conducted with a focus on the goals cited above

Contact Information:

Bruce Swett, Acting Principal Investigator
450 Prospect Road
Pembroke, NC 28372
Phone: 910-522-0900

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South Puget Intertribal Planning Agency, SPIPA (Shelton, WA)

Expanding the Circle of Care

Target Population: Community members of the Squaxin Island, Nisqually, and Shoalwater Bay Tribes of Washington State

Goal: 1. Increase the number of HIV-positive American Indians who are receiving comprehensive and culturally relevant care; 2. Increase the number of tribal members who know their HIV status; 3. Increase awareness of HIV risk factors

Strategies: 1. Facilitate the entry into comprehensive HIV primary care through the use of Tribal HIV/AIDS Advocates who provide outreach and referrals to care services; 2. Develop an education/outreach campaign for youth and a "Prevention for Positives" campaign for individuals living with HIV/AIDS; 3. Sponsor community events such as tribal health fairs and festivals, which include HIV counseling and testing

Evaluation: Project evaluation activities will focus on changes in tribal community knowledge, attitudes, beliefs, and behaviors over time through annual community surveys and focus groups, in addition to tracking of group and outreach activities

Contact Information:

Carmen Kalama, Project Director
2970 SE Old Olympic Hwy
Shelton, WA 98584
Phone: 360-426-3990

Urban Indian Health Board
(Oakland, CA)

Holistic Native Network

Target Population: HIV-infected Native Americans in the San Francisco Bay area

Goal: Increase adherence to HIV and substance abuse/mental health treatment plans and increase use of services used by Native Americans unaware of their HIV status

Strategies: Develop an integrated health care system to provide case management, Holistic HIV mental health services, and psychotherapy/counseling

Evaluation: Evaluation activities will focus on increased use of health services, increased service coordination, reduction in risky behaviors, and improved quality of life of participants

Contact Information:

Ethan Nebelkopf, PhD, Principal Investigator
3124 International Blvd
Oakland CA 94601
Phone: 510-535-4440

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Yukon Kuskokwim Health Corporation (Bethel, AK)

Circle of Care HIV/AIDS Project

Target Population: Alaska Native/American Indian individuals 18-64 years old

Goal: 1. Increase the number in the target population who know their HIV status; 2. Increase adherence to HIV treatment; 3. Increase the knowledge and skill level of health care workers; 4. Create community awareness of HIV/AIDS issues

Strategies: HIV testing and counseling, training of health care workers, a community-wide education and media campaign including radio PSA's, posters, brochures, and presentations, and development of collaborations between agencies and other resources

Evaluation: The project will collect village knowledge, attitudes, and beliefs about HIV and HIV testing by implementing a community survey

Contact Information:

Andrea Savage, MPH, MSW, Project Coordinator
P.O. Box 528
Bethel, AK 99559
Phone: 907-543-6941

University of Oklahoma (Norman, OK)

National American Indian/Alaska Native HIV/AIDS Technical Assistance Center

Goal: To assist the AI/AN grantees with program evaluation, data management, data analysis, and dissemination of findings

Strategies: 1. Coordination of the initiative via annual meetings, site visits, a web page, and telephone communications; 2. Assistance with local needs assessment, development of logic and service delivery models as well as IRB protocols, and data analysis; 3. Assist in the development of local research questions and measurement issues with a focus on removing barriers to HIV primary care and identifying the best models for integrative care; 4. Host grantee meetings with a focus on skills building in the areas of program evaluation, IRB protocols, use of health and social theory in model design, and dissemination of local project activities; 5. Dissemination of outcomes, lessons learned, and best practice findings

Evaluation: Evaluation will include assessment of barriers and challenges faced by each grantee in addition to a multi-site evaluation of common outcome variables

Contact Information:

Morris Foster, PhD, Principal Investigator
Univeresity of Oklahoma
Department of Anthropology
3200 Marshall Avenue
Norman, OK 73069
Phone (405) 325-0442