Behavioral and Clinical Characteristics of American Indian/Alaska Native Adults in HIV Care — Medical Monitoring Project, United States, 2011–2015

The rate of diagnosis of human immunodeficiency virus (HIV) infection among American Indians and Alaska Natives (AI/ANs) in 2016 (10.2 per 100,000 population) was the fourth highest among seven racial/ethnic groups in the United States (1); the number of diagnoses of HIV infection among AI/AN persons increased by 70%, from 143 in 2011 to 243 in 2016 (1). However, little has been published about the sociodemographic, behavioral, and clinical characteristics of AI/AN patients with HIV infection in care because small sample sizes have led to infrequent analysis of AI/AN-specific estimates (2) and because of underestimation of AI/AN race/ethnicity in surveillance and other data sources (3). CDC analyzed data from the Medical Monitoring Project (MMP), a surveillance system that collects information about the experiences and needs of persons with diagnosed HIV infection, collected during 2011–2015 among AI/AN adults receiving HIV medical care. The results indicated that 64% of AI/AN patients with HIV infection in care achieved sustained viral suppression, and 76% achieved viral suppression at their most recent viral load test within the past 12 months, which is below the national HIV prevention goal of 80%, but comparable to or better than some other racial/ethnic groups (4). Based on self-report, 51% of AI/AN patients with HIV infection had incomes at or below the U.S. Department of Health and Human Services’ (HHS) annual poverty limit, 27% had symptoms of depression, 78% reported internalized HIV-related stigma, and 20% reported binge drinking in the past 30 days. To improve the health of AI/AN patients with HIV infection, it is important that health care providers, tribal organizations, and state and local health departments consider the sociodemographic and behavioral barriers to AI/AN patients with HIV infection achieving viral suppression and design care plans that seek to eliminate those barriers.

MMP used a three-stage sample design (states and territories, facilities, patients). Response rates were 100% (states and territories), 83%–85% (range across cycles for facilities), and 49%–55% (patients). Data were collected using face-to-face or telephone interviews and medical record abstraction during June 2011–May 2015. Data were weighted for unequal selection probabilities and nonresponse (5). Weighted prevalence estimates describing the sociodemographic, behavioral, and clinical characteristics of AI/AN patients with HIV infection in care were calculated with accompanying 95% confidence intervals (CIs). Based on mental health results found in this descriptive analysis, mental health and peer group support services received and needed were also described.

AI/AN classification was determined by self-identified AI/AN race, regardless of ethnicity or other racial group identity (2). Poverty was defined as income at or below the HHS annual poverty guidelines.* Depression was defined as self-reported symptoms consistent with a diagnosis of major/other depression in the past 2 weeks based on the Patient Health Questionnaire-8 (PHQ-8) scale with major/other depression defined as a PHQ-8 score ≥2. Binge drinking was defined as consumption of four or more (females) or five or more (males) alcoholic drinks in one sitting in the past 30 days. Antiretroviral therapy (ART) adherence was defined as taking all prescribed HIV medicines in the past 3 days. Sustained viral suppression was defined as <200 copies of viral RNA/mL in all viral load tests during the past 12 months. Need for support services was defined as needing, but not receiving, mental health or HIV peer group support services during the past 12 months.

AI/AN patients (666) accounted for 3.6% (95% CI = 3.1–4.1) of the MMP population. Among AI/AN patients with HIV infection, 65% identified as being part of more than one racial group, and 29% identified as Hispanic/Latino ethnicity (Table 1). Fifty-one percent had household incomes at or below the HHS poverty guidelines, 12% experienced homelessness in the past 12 months, and 6% had been incarcerated in the past 12 months. Internalized HIV-related stigma^† was reported by 78% of patients, and 37% experienced health care discrimination since testing positive for HIV.^§

Among AI/AN patients with HIV infection in care, 27% had symptoms consistent with major/other depression in the past 2 weeks, 12% were dissatisfied with their social support, 20% reported binge drinking, 32% used noninjection drugs in the past 12 months, 5% injected drugs in the past 12 months, and 46% currently smoked cigarettes (Table 2). Eight percent of AI/AN patients with HIV infection had condomless sex with a partner who had a negative or unknown HIV status while the patient was not sustainably virally suppressed during the past 12 months. In terms of clinical characteristics, 86% of AI/AN patients on ART were adherent, 64% had achieved sustained viral suppression, and 76% had achieved viral suppression as of their most recent viral load test in the past 12 months.

Peer support group services were received by 17% of AI/AN patients, whereas 11% needed but did not receive these services (Figure). Approximately one third of AI/AN patients received mental health services, and 8% needed but did not receive mental health services.

Acknowledgments

Participating Medical Monitoring Project respondents, facilities, providers, advisory boards, and project areas.

Corresponding author: Amy R. Baugher, [email protected], 404-639-1956.

¹Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC; ²Epidemic Intelligence Service, CDC; ³ICF International, Rockville, Maryland.

References

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Abbreviation: CI = confidence interval.
* Self-identified AI/AN race, regardless of ethnicity or other racial groups.
^† Percentages are weighted percentages and might not sum to 100% because of rounding.
^§ 95% CIs incorporate weighted percentages
^¶ Patients were classified as transgender if sex at birth and gender reported by patient were different, or if patient’s gender identity was transgender.
** Poverty guidelines as defined by the U.S. Department of Health and Human Services. https://aspe.hhs.gov/poverty/faq.cfm.
^†† Living on the street, in a shelter, in a single-room-occupancy hotel, or in a car.
^§§ Agreed with any of the following statements: it is difficult to tell people about my HIV infection, being HIV-positive makes me feel dirty, I feel guilty that I am HIV positive, I am ashamed that I am HIV-positive, I sometimes feel worthless because I am HIV-positive, and I hide my HIV status from others.
^¶¶ Health care discrimination was defined as a health care worker exhibiting hostility or lack of respect, giving the patient less attention than others, or refusing the patient service since the patient tested positive for HIV.

Abbreviations: ART = antiretroviral therapy; CI = confidence interval.
* Self-identified AI/AN race, regardless of ethnicity or other racial groups.
^† Percentages are weighted percentages and might not sum to 100% because of rounding.
^§ 95% CIs incorporate weighted percentages.
^¶ Consumption of four or more (females) or five or more (males) alcoholic drinks in one sitting in the past 30 days.
** Taking all prescribed HIV medicines in the past 3 days.

FIGURE. Mental health and peer group support service needs* among American Indian/Alaska Native (AI/AN)^† adults receiving human immunodeficiency virus (HIV) care (N = 666) — Medical Monitoring Project, United States, 2011–2015

* Need was defined as needing, but not receiving mental health or HIV peer group support services during the past 12 months.

^† Self-identified AI/AN race, regardless of ethnicity or other racial groups.