Working with a regional coalition to improve STD and HIV/AIDS prevention and control in Northern Plains Tribal communities Ann Drobnik, MPH BETAH Associates, Inc. Northern Plains Tribal Epidemiology Center Aberdeen Area Tribal Chairmen’s Health Board

NPTEC/AATCHB Background Aberdeen Area Tribal Chairmen’s Health Board formed in 1985 to serve as an advocate for Northern Plains Tribes and a liaison between the Tribes and Indian Health Service Aberdeen Area Tribal Chairmen’s Health Board formed in 1985 to serve as an advocate for Northern Plains Tribes and a liaison between the Tribes and Indian Health Service Northern Plains Tribal Epidemiology Center opened in 2003 to provide Tribes with technical assistance, capacity building and improved access to data on health issues Northern Plains Tribal Epidemiology Center opened in 2003 to provide Tribes with technical assistance, capacity building and improved access to data on health issues CDC contract with BETAH Associates began in 2005 to provide STD and HIV capacity building in response to high rates in the region. CDC contract with BETAH Associates began in 2005 to provide STD and HIV capacity building in response to high rates in the region.

NPTEC/AATCHB office Rapid City, SD

Aberdeen Area Tribes –Santee Sioux Tribe of Nebraska –Ponca Tribe of Nebraska –Omaha Tribe of Nebraska –Winnebago Tribe of Nebraska –Sac & Fox Tribe of the Mississippi –Turtle Mountain Band of Chippewa –Trenton Indian Service Area (Chippewa) –Oglala Sioux Tribe –Rosebud Sioux Tribe –Cheyenne River Sioux Tribe –Standing Rock Sioux Tribe –Lower Brule Sioux Tribe –Crow Creek Sioux Tribe –Yankton Sioux Tribe –Spirit Lake Sioux Tribe –Sisseton Wahpeton Oyate –Flandreau Santee Sioux Tribe

Area Background Aberdeen Indian Health Service Administrative Area covers IA, NE, NE, SD Aberdeen Indian Health Service Administrative Area covers IA, NE, NE, SD Vast and rural, many Tribal communities are remote and isolated Vast and rural, many Tribal communities are remote and isolated Highest STD rates of any of the IHS service areas Highest STD rates of any of the IHS service areas Disparate rates of STDs and HIV in all four states Disparate rates of STDs and HIV in all four states Complex historical relationships between the Tribes, states, and IHS Complex historical relationships between the Tribes, states, and IHS

Aberdeen Area Chlamydia Rates Wong D, Swint E, Paisano EL, Cheek, JE. Indian Health Surveillance Report – Sexually Transmitted Diseases Atlanta, GA: DHHS, CDC, and IHS, November 2006.

Aberdeen Area STD/HIV Task Force Task Force formed in 2004 to increase collaboration and communication between IHS, Tribes and State Health Departments Task Force formed in 2004 to increase collaboration and communication between IHS, Tribes and State Health Departments Forum for increased communication, knowledge sharing, and collaboration Forum for increased communication, knowledge sharing, and collaboration Task Force meets by teleconference 8-10 times a year Task Force meets by teleconference 8-10 times a year Currently 47 members; 30 active members Currently 47 members; 30 active members

Task Force Membership Aberdeen Area Indian Health Service Aberdeen Area Indian Health Service Public health nurses Public health nurses Clinical nurses Clinical nurses Tribal health educators Tribal health educators Community health representatives Community health representatives State Departments of Health State Departments of Health State Departments of Education* State Departments of Education* CDC CDC Universities* Universities* Dakota AIDS Education and Training Center** Dakota AIDS Education and Training Center** National organizations National organizations *joined in 2006, **joined in 2007

Strategic Plan Development In January 2006, Task Force began working on a regional strategic plan for Aberdeen Area Tribal communities In January 2006, Task Force began working on a regional strategic plan for Aberdeen Area Tribal communities Strategic Plan completed in July 2006 Strategic Plan completed in July 2006 Action Plan completed in February 2007 Action Plan completed in February 2007 Currently working on implementation Currently working on implementation

Strategic Plan Development Development required input from all parties – States, Tribes, IHS Development required input from all parties – States, Tribes, IHS History of tribal disempowerment by state and federal government entities History of tribal disempowerment by state and federal government entities Lack of trust among members Lack of trust among members

Strategic Plan Purpose To identify common goals: To identify common goals: –Reducing incidence of STDs and HIV/AIDS in the Native population –Increasing screening, education and outreach, and prevention interventions –Improving follow-up with patients to ensure treatment and testing of partners

Strategic Plan Purpose To identify unmet needs: To identify unmet needs: –Lack of, or perceived lack of confidential, culturally competent care –Few prevention interventions, particularly evidence-based evaluated in Native populations –No culturally-specific educational materials –Lack of community awareness

Strategic Plan Purpose To identify available resources: To identify available resources: –Model programs or projects in the area –Training resources –Other health programs –Programs serving high-risk populations

Identification of Strengths Health personnel that are members of the community Health personnel that are members of the community Open-mindedness, and willingness to discuss STD/HIV among youth Open-mindedness, and willingness to discuss STD/HIV among youth Communities interested in learning about STDs and HIV Communities interested in learning about STDs and HIV Elders Elders Cultural traditions and spirituality Cultural traditions and spirituality Strong partnerships in some areas between IHS facilities and tribal health programs Strong partnerships in some areas between IHS facilities and tribal health programs Strong partnerships in some areas between IHS facilities and state service providers Strong partnerships in some areas between IHS facilities and state service providers Strong relationships between health programs or service units and local schools Strong relationships between health programs or service units and local schools Local level multi-sector Task Forces Local level multi-sector Task Forces Tribally run drug and alcohol treatment facilities Tribally run drug and alcohol treatment facilities

Identification of Barriers Stigma around STDs and HIV Stigma around STDs and HIV STDs and HIV as taboo topics STDs and HIV as taboo topics Historical trauma Historical trauma Intergenerational grief Intergenerational grief Lack of funding Lack of funding Shortage of personnel to carry out activities Shortage of personnel to carry out activities High turnover among health providers High turnover among health providers Clinical staff are not part of community Clinical staff are not part of community Lack of community awareness of resources available Lack of community awareness of resources available Resistance of schools to address STDs and HIV with students Resistance of schools to address STDs and HIV with students Substance abuse, particularly methamphetamine use Substance abuse, particularly methamphetamine use Geographic distance of patients from services Geographic distance of patients from services Lack of confidentiality or perception of lack of confidentiality Lack of confidentiality or perception of lack of confidentiality

Priority Populations Youth Youth Women Women Injection drug users Injection drug users LGBTQ/MSM LGBTQ/MSM Parents Parents Elders Elders

Methods Needs assessment Needs assessment Regular conference calls Regular conference calls Individual interviews Individual interviews In-person meetings In-person meetings

Needs Assessment NPTEC conducted a needs assessment of STD and HIV prevention and control services and activities in 2005 NPTEC conducted a needs assessment of STD and HIV prevention and control services and activities in 2005 Clinical and community health staff representing 10 of the 18 reservations participated Clinical and community health staff representing 10 of the 18 reservations participated Identified a need for culturally-specific educational materials, clinical and community training, behavior change interventions, and more outreach Identified a need for culturally-specific educational materials, clinical and community training, behavior change interventions, and more outreach

Conference Calls Strengths Sparked group discussion Sparked group discussion Many view points represented Many view points representedLimitations Not all members present for each call Not all members present for each call Tendency for Tribal members not to offer their opinions in a group setting Tendency for Tribal members not to offer their opinions in a group setting

Individual Interviews Strengths Gave less vocal members an opportunity to contribute their ideas Gave less vocal members an opportunity to contribute their ideas Allowed members to be honest about their concerns Allowed members to be honest about their concerns Allowed cultural components to be addressed Allowed cultural components to be addressed Helped to build trust and relationships with Tribal members Helped to build trust and relationships with Tribal membersLimitations Not all members completed an interview Not all members completed an interview

In-person Meetings Presentations to Tribal health committees, at local meetings and conferences Presentations to Tribal health committees, at local meetings and conferences Helped to build trust and relationships Helped to build trust and relationships Allowed for input from community members and Tribal leaders who were not part of the Task Force Allowed for input from community members and Tribal leaders who were not part of the Task Force Built support for the strategic planning effort at the local level Built support for the strategic planning effort at the local level

The Plan: Clinical Components Increase screening for the most common STDs (chlamydia and gonorrhea) and HIV Increase screening for the most common STDs (chlamydia and gonorrhea) and HIV –Within the clinical setting –Outside the clinical setting Improve risk reduction counseling, treatment and partner services Improve risk reduction counseling, treatment and partner services Establish referral networks Establish referral networks

The Plan: Community Components Increase quantity and quality of community outreach and education Increase quantity and quality of community outreach and education Develop Native-specific social marketing and education materials Develop Native-specific social marketing and education materials Expand risk-reduction interventions targeting high-risk groups Expand risk-reduction interventions targeting high-risk groups Expand school-based prevention education Expand school-based prevention education

Progress to Date First face-to-face meeting of the Task Force held in May of 2007 First face-to-face meeting of the Task Force held in May of 2007 Trainings held on partner services, HIV prevention counseling, rapid HIV testing and hepatitis integration and STD/HIV 101 Trainings held on partner services, HIV prevention counseling, rapid HIV testing and hepatitis integration and STD/HIV 101 Dissemination of IHS guidelines on school and jail screening Dissemination of IHS guidelines on school and jail screening Creation of regional resource guide to assist with referrals Creation of regional resource guide to assist with referrals

Progress to Date Patient educational materials with local statistics, contact information and graphic design Patient educational materials with local statistics, contact information and graphic design Social marketing campaign targeting youth Social marketing campaign targeting youth Planning for peer education and intergenerational program development Planning for peer education and intergenerational program development Review of curricula for possible use in schools Review of curricula for possible use in schools Collaboration with a wider network of partners – training centers and universities Collaboration with a wider network of partners – training centers and universities Task Force membership expanded to include more Tribes Task Force membership expanded to include more Tribes

Model Projects Chlamydia school screening projects on two reservations Chlamydia school screening projects on two reservations Male screening pilot projects on two reservations Male screening pilot projects on two reservations In Community Spirit project providing HIV prevention education to Native women in South Dakota In Community Spirit project providing HIV prevention education to Native women in South Dakota Community hepatitis screening, treatment and care project Community hepatitis screening, treatment and care project Intergenerational project on HIV/STD prevention and Lakota traditions Intergenerational project on HIV/STD prevention and Lakota traditions

On-going Challenges Lack of or minimal participation from some Tribes, Service Units and State Health Departments Lack of or minimal participation from some Tribes, Service Units and State Health Departments Funding for implementation Funding for implementation Working with schools Working with schools Lack of evidence-based, culturally appropriate interventions and curricula Lack of evidence-based, culturally appropriate interventions and curricula Turnover at Aberdeen Area IHS Turnover at Aberdeen Area IHS Change in Task Force leadership Change in Task Force leadership

Next Steps Continuation of subcommittee work to further develop other components of the strategic plan Continuation of subcommittee work to further develop other components of the strategic plan Follow-up with Tribal leaders to report on progress of the plan Follow-up with Tribal leaders to report on progress of the plan Local planning meetings to implement the activities at the local level Local planning meetings to implement the activities at the local level Expansion of model projects Expansion of model projects Continuation of efforts to improve relations between Tribes and state health departments Continuation of efforts to improve relations between Tribes and state health departments

Thank you! Questions?

Contact Information Ann Drobnik, MPH Phone: