1. Project Red Talon STD/HIV Prevention January 2007 Northwest Portland Area Indian Health Board

2. MISSION: To assist Northwest tribes to improve the health status and quality of life of member tribes and Indian people in their delivery of culturally appropriate and holistic health care.

4. Agenda 1.Red Talon STD/HIV Coalition 2.Red Talon Profile 3.Profile Findings: Statistics & Recommendations 4.Tribal Action Plan 5.Next Steps

5. Red Talon STD/HIV Coalition Mission: Our goal is to reduce the prevalence of STDs among American Indians and Alaska Natives in the Pacific Northwest by uniting to share wisdom, data, and resources, identify and address common priorities, and develop strategies to eliminate STD-related disparities.

6. Red Talon Profile Project Red Talon (PRT) & Northern Plains Tribal Epidemiology Center (NPTEC) A comprehensive Tribal STD/HIV Capacity Assessment Survey Over 90 respondents in 2005 Over 60 respondents in 2006

7. Red Talon Profile Chapter 1: Introduction Chapter 2: Tribal Clinic STD Testing and Treatment Practices Chapter 3: Tribal STD Prevention Activities Chapter 4: Chlamydia Chapter 5: Gonorrhea Chapter 6: Syphilis Chapter 7: HIV/AIDS Chapter 8: Hepatitis A, B, and C Chapter 9: NW Tribal STD Priorities and Recommendations Chapter 10: Related Definitions, Tables, and Appendices

8. Profile Findings: Statistics Chlamydia: In Oregon, Washington, and Idaho, American Indian and Alaska Native (AI/AN) women are nearly three times more likely to be diagnosed with Chlamydia than non-Native women, and AI/AN men are twice as likely to be diagnosed. Gonorrhea: In the U.S. as a whole, gonorrhea rates among AI/ANs are slightly lower than gonorrhea rates reported for “All Races” combined. This success is not demonstrated in the NW however, where AI/AN gonorrhea rates are nearly twice that of the total population. Syphilis: Since 1997, AI/AN rates in the Northwest states have been lower than rates for the total population. HIV / AIDS: At 10.4 cases per 100,000, American Indians and Alaska Natives had the 3rd highest AIDS rate in 2003, in relation to other ethnic groups. Hepatitis: In 2002, the Hepatitis B rate among AI/ANs was second only to non- Hispanic blacks.

9. Red Talon Profile CDC – Reportable Infections Using these records, data by age, race, and sex are available from 1981-2003.

10. Chlamydia

14. Gonorrhea

18. Syphilis

21. HIV/AIDS

22. Estimated number of HIV/AIDS cases, by year of diagnosis and race/ethnicity: 35 areas with confidential name-based HIV infection reporting, 2001–2004 Year of Diagnosis 2001200220032004 White, not Hispanic11,24211,35211,09711,806 Black, not Hispanic21,55620,23719,31019,206 Hispanic7,7146,9647,0786,970 Asian/Pacific Islander279319367394 American Indian/Alaska Native 171202187208 Note. These numbers do not represent reported case counts. Rather, these numbers are point estimates, which result from adjustments of reported case counts. The reported case counts are adjusted for reporting delays and for redistribution of cases in persons initially reported without an identified risk factor. The estimates do not include adjustment for incomplete reporting. Data include persons with a diagnosis of HIV infection. This includes persons with a diagnosis of HIV infection only, a diagnosis of HIV infection and a later AIDS diagnosis, and concurrent diagnoses of HIV infection and AIDS. Since 2000, the following 35 areas have had laws or regulations requiring confidential name-based HIV infection reporting: AL, AK, AZ, AR, CO, FL, ID, IN, IA, KA, LO, MI, MN, MI, MO, NE, NV, NJ, NM, NY, NC, ND, OH, OK, SC, SD, TE, TX, UT, VI, WV, WI, WY, Guam and the U.S. Virgin Islands. Since July 1997, Florida has had confidential name-based HIV infection reporting only for new diagnoses. Source: Table 1. Cases of HIV Infection and AIDS in the United States, 2004. HIV/AIDS Surveillance Report, Volume 16. CDC.

23. Estimated numbers of cases and rates of HIV/AIDS, by race/ethnicity: 33 states with confidential name-based HIV infection reporting, 2004 Adults and adolescents MalesFemalesTotal Race/ethnicityNo. Rate No. Rate No. Rate White, not Hispanic10,01018.71,7823.211,79110.7 Black, not Hispanic12,048131.67,0096719,05797.2 Hispanic5,51760.21,40016.36,91639 Asian/Pacific Islander29913.9944.13938.9 American Indian/Alaska Native 14820.8577.720514.1 Total28,11737.610,39113.238,50825.1 Note. These numbers do not represent reported case counts. Rather, these numbers are point estimates, which result from adjustments of reported case counts. The reported case counts are adjusted for reporting delays. The estimates do not include adjustment for incomplete reporting. Data include persons with a diagnosis of HIV infection. This includes persons with a diagnosis of HIV infection only, a diagnosis of HIV infection and a later AIDS diagnosis, and concurrent diagnoses of HIV infection and AIDS. Source: Table 5b. Cases of HIV Infection and AIDS in the United States, 2004. CDC.

25. Cumulative Washington State HIV Cases by Race/Ethnicity: Through July 31, 2006 Race/Ethnicity Adult/Adolescent PediatricTotal MaleFemale White, not Hispanic2,695300113,006 Black, not Hispanic41819219629 Hispanic (all races)299546359 Asian/Pacific Islander2406 Asian85124101 Hawaiian/Pacific Isl.8109 AI/AN3426060 Multi-race182020 Unknown343037 Total3,593594404,227 Source: Table 3. Washington State HIV/AIDS Surveillance Report - 07/31/2006, WA DOH.

26. Cumulative Washington State AIDS Cases by Race/Ethnicity: Through July 31, 2006 Race/Ethnicity Adult/Adolescent PediatricTotal MaleFemale White, not Hispanic8,285552158,852 Black, not Hispanic1,016283101,309 Hispanic (all races)760914855 Asian/Pacific Islander3113145 Asian135180153 Hawaiian/Pacific Isl.218029 AI/AN160521213 Multi-race355141 Unknown102012 Total10,4531,0243211,509 Source: Table 4. Washington State HIV/AIDS Surveillance Report - 07/31/2006, WA DOH.

27. Clinic Capacity

28. Profile Findings: Statistics 2005 - Screening and Testing:  For the most part, tribal health clinics did not consider the majority of sexually transmitted diseases clinical priorities.  Almost all clinics represented in the survey provided at least some screening or testing for sexually transmitted diseases.  In all cases, treatment rates lagged well behind STD screening/testing rates (i.e. only 1/3 of those who reported testing for Hepatitis C also provided treatment for the disease).  On average, 3/4 of clinicians reported that their clinic regularly tests for sexually transmitted diseases, while only 40% reported capacity to treat the conditions.

29. Treatment - 2005

31. Profile Findings: Statistics 2006 - Screening and Testing:  All respondents indicated that that their clinic provides testing for chlamydia, gonorrhea, and syphilis. Slightly fewer clinicians reported the ability to test for HIV, Hepatitis (A, B, and C), Herpes, and HPV. Several clinics indicated that AIDS diagnoses and treatment services were referred out.  All respondents indicated that that their clinic provides treatment for chlamydia, gonorrhea, and syphilis. Few respondents (36%) indicated that HIV/AIDS treatment was provided.  These rates suggest significant improvements from 2005, when 75-80% of clinic STD Capacity Assessment respondents indicated that they did not provide chlamydia, gonorrhea, or syphilis treatment. HIV treatment also appears to have increased, from 11% in 2005 to 36% in 2006.

32. Profile Findings: Statistics 2006 - Screening:  Respondents that did not provide asymptomatic STD screening to patients were most likely attribute this to “Patient discomfort with STD testing (43%)” and “Insufficient training on recommended guidelines (29%).”  Lab costs and a lack of consistent policies were also named as potential barriers.

33. Profile Findings: Statistics 2006 - Treatment:  Of those respondents who indicated their clinic did not provide treatment for one or more STDs/HIV:  60% attributed this to insufficient training on the current STD treatment guidelines  40% attributed this to the cost of drugs  40% attributed this to referral to outside practitioners  20% attributed this to drug unavailability on their clinic’s formulary.

34. Profile Findings: Statistics 2005 - Reporting:  Only 56% of respondents indicated that their clinic upheld a clinical protocol to report STD cases to the local or state STD registry.  Reporting rates ranged from a high of 70% for gonorrhea and syphilis, to 67% for chlamydia, 64% for AIDS, 50% for Hepatitis C, and 43% for HIV.

35. Profile Findings: Statistics 2006 - Reporting:  All respondents indicated that that their clinic reports new cases of chlamydia and gonorrhea to their State or County Health Department. Slightly fewer indicated that syphilis, HIV, and Hepatitis (A, B, and C) were regularly reported. Nearly half of respondents indicated that they did not report Herpes or HPV, which is consistent with reporting requirements in the NW.  These rates suggest significant improvements from 2005.

36. Profile Findings: Statistics 2006 - Policies:  When asked about specific clinic policies, all respondents indicated that:  All patients receive confidential STD/HIV services in accordance with HIPPA regulations.  Clinic Operations Manual contains policies and procedures to manage occupational blood exposure for healthcare workers.  The clinic provides condoms and counseling on primary prevention to all patients.  Clinicians follow current CDC-recommended treatment guidelines for all STDs.

37. Profile Findings: Statistics 2006 - Policies:  Inconsistent with these results, respondents were least likely to indicate that the CDC’s STD screening guidelines were being met by their clinic for young, sexually active males (8%) and females (38%), though older males and females with known risk factors were slightly more likely to be screened at least once per year (54%).  Routine, voluntary HIV screening was somewhat more likely to occur (at 58%), and 82% of respondents indicated that STD screening regularly occurs during prenatal visits for all pregnant women.

38. Profile Findings: Recommendations NW Tribal members identified three essential objectives:  Increase community awareness about STDs.  Strengthen local capacity to prevent STDs.  Improve STD screening and treatment in Tribal clinics.

39. Tribal Action Plan

40. Increase Community Awareness:  Build awareness among Tribal Council Members and decision- makers.  Educate community members at community gatherings.  Develop and implement a comprehensive, culturally appropriate STD media campaign. Tribal Action Plan

41. Strengthen Local Capacity to Prevent STDs:  Increase funding.  Improve collaboration and networking.  Increase STD training among tribal health advocates.  Support prevention programs. Tribal Action Plan

42. Improve STD Screening and Treatment in Tribal Clinics:  Strengthen clinic screening and treatment policies.  Increase community participation in screening campaigns.  Minimize barriers to testing and treatment. Tribal Action Plan

43. Next Steps 1.Year Two of the Action Plan 2.PRT Trainings 3.STD/HIV Media Campaign 4.Support the development of Clinic Policies

44. Questions?