In This Issue
Upcoming Events

Circle of Harmony Native American HIV/AIDS Conference

April 20-22, 2015

Albuquerque, NM

Hosted by the Albuquerque Area Indian Health Board

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National HIV Prevention Conference¬ 

December 6-9, 2015

Atlanta, GA

 

Facebook Launches Suicide Prevention Initiative

 Social media giant Facebook launched a new set of intervention tools in collaboration with Forefront: Innovations in Suicide Prevention, a University of Washington School of Social Work organization. When Facebook users come across a post from a friend that worries them, they can mark post as something that should not be on Facebook because it is, "harmful, threatening or suicidal." From there Facebook gives the reporter five options: message your friend, reach out to another friend to have support, chat with a trained helper, call Lifeline, or ask Facebook to take a look at the post. Should the reporter chose to reach out to the friend potentially in distress, Facebook has suggestions to aid in creating dialogue. Should Facebook be requested to review the post, they either send resources and tools to the person in distress, or request a welfare check with local law enforcement agencies.

 

For more information, visit Facebook's Safety website.

 

CDC Report Finds AI/AN Populations Experience Higher Rates of New Infections

According to the Centers for Disease Control and Prevention's Morbidity and Mortality Weekly Report from January 16, 2015, American Indian and Alaska Native populations experienced higher rates of new infections than non-Hispanic white populations in 14 of 26 reportable infection diseases during 2007-2011. Although incidence rates of some infectious diseases have declined in American Indian and Alaska Native populations, disparities between groups remain.

 

The CDC analyzed data from the National Notifiable Diseases Surveillance System that collects reports on nationally notifiable diseases in the United States and its territories. Interventions are needed to reduce disparities in chlamydia, gonorrhea, West Nile virus, spotted fever rickettsiosis, and other infections among AI/AN and NHW populations.
Tribal Epidemiology Centers (TECs)
Anchorage, Alaska

Albuquerque, New Mexico

Sacramento, California

Lac du Flambeau, Wisconsin

Phoenix, Arizona

Window Rock, Arizona

Rapid City, South Dakota

Portland, Oregon

Oklahoma City, Oklahoma

Billings, Montana

Nashville, Tennessee

Seattle, Washington
Public Health Digest 
A Publication of the National Indian Health Board 
Mission of the National Indian Health Board

One Voice affirming and empowering American Indian and Alaska Native peoples to protect and improve health and reduce health disparities.


This Publication
The National Indian Health Board (NIHB) invites you to learn more about the latest developments in Tribal public health, including updates on NIHB's current projects.  We also invite you to share your news items, comments or questions. 
Tribal Leaders Diabetes Committee Meets with IHS Acting Director
The Tribal Leaders Diabetes Committee met February 4-5 at the IHS Headquarters in Rockville, Maryland

The Tribal Leaders Diabetes Committee (TLDC) was established in 1997 in response to the successful partnership between IHS and Tribal leaders in establishing the process for distributing the

Special Diabetes Program for Indians (SDPI)
funds. Congress established the SDPI to provide funding to address the growing epidemic of diabetes in American Indian/Alaska Native (AI/AN) communities. By creating this Committee, the Indian Health Service (IHS) Director sought to foster an ongoing dialogue between IHS and Tribal leadership on matters related to diabetes and chronic health conditions among AI/ANs. The TLDC is an important outcome of the SDPI and demonstrates the true spirit of ongoing partnership between Tribal and IHS leadership.

 

Most recently, the TLDC met in Rockville, Maryland with IHS leadership to make recommendations on the FY2016 national consultation process and distribution of SDPI funds. There were over 35 people present for the meeting and 11 of the twelve IHS Areas were represented in the discussion. The final decisions on how to move forward for FY2016 will be made by the IHS Acting Director if SDPI is renewed by Congress in March, 2015.

 

Tribal leaders meet with Jamie Herrera Beutler (R-WA)
In conjunction with their meeting with IHS, Tribal leaders visited the National Indian Health Board's offices in Washington, DC and visited elected officials on Capitol Hill on February 3, 2015 to provide outreach and education to Congress on the successes of SDPI programming. Fifteen individuals, including Tribal leaders, participated in visits to eleven congressional offices to meet with federal legislators and their staff to provide information, share stories, discuss diabetes and the SDPI in Indian Country. NIHB supported these volunteers in their visits by assisting them with creating and delivering relevant materials and setting up appointments. The group met with members of both the House of Representatives and the Senate, and included representatives from the Astariwi Band of Pit River Indians; Cow Creek Band of Umpqua Tribe of Indians; Cowlitz Indian Tribe; Fort Belknap Indian Community; Navajo Nation; Pueblo of Zuni; the Santa Ynez Band of Chumash Indians; Sault Ste. Marie Tribe of Chippewa Indians; and the Tohono O'Odham Nation.

 

The Tribal leaders that serve on the TLDC are passionate about working to reverse the devastating impacts that diabetes and chronic diseases can have on AI/AN communities and people. Rosemary Nelson, the California Area TLDC representative, stated, "The Tribes across the nation have proven that they deserve to have SDPI reauthorized. The Special Diabetes Program for Indians has shown a reduction of 43% of end-stage renal disease patients in Indian Country. This significant reduction in kidney disease saves thousands of dollars, cuts medical costs and most importantly, it saves lives. This program is a win-win partnership and that is why I serve on the Tribal Leaders Diabetes Committee."

 

Please visit www.nihb.org/sdpi for more information about the Special Diabetes Program for Indians.

Wise Practices: Linking Culture and Programming
When discussing prevention treatment practices in the United States, the conversation tends to include best practices. Best practices are guidelines or practices driven by clinical wisdom, professional organizations, or other consensus approaches that do not necessarily include systematic use of available research. In its publication, Foundations of a Good Practices Approach, the Canadian Aboriginal AIDS Network (CAAN) objected to using the term best practices for two reasons, 1) there is no "best" practice, and 2) one model does not fit all.[i] It was argued that what may work in one community may not work "best" in other communities. More importantly, best practices tend to be Euro-American centric, without Tribal considerations. While best practices are widely accepted and largely effective in Indian Country, there is still a crucial component often missing: culture.

 

CAAN's published objections have since lead to a larger dialogue within the Indigenous community in Canada. In his publication, Leading an Extraordinary Life: Wise Practices for an HIV Prevention Campaign With Two-Spirit Men, J. Michael Thoms acknowledged CAAN's objections to the terminology and instead coined a new term-wise practices. He defined wise practices as interventions and protocols that are reflective of indigenous peoples' worldview and ways of creating knowledge.[ii] This isn't far off base from practice-based evidence, or a range of treatment approaches and supports that are derived from, and supportive of, the positive culture of the local society and traditions. Wise practices are treatment approaches that specifically recognize Indigenous self-determination and knowledge.

Many Tribal programs already incorporate tradition and culture into their programs. Some Tribes use Seven Grandfather or Medicine Wheel teachings. Other tribes incorporate talking circles, sweat lodges, and traditional ceremonies and medicine. For Tribes that have not yet incorporated culture or tradition into their programming, it is encouraged that you work with a community advisory board comprised of Elders, traditional advisors, Tribal leaders, and other community members to examine and adapt a Western best practice in order to appropriately integrate cultural elements that can contribute to and help sustain behavior change. While best practices aren't always culturally relevant, they still carry a great deal of merit. Working with an advisory board and consequently conducting a community assessment to see where gaps in best practices may exist will allow Tribes to provide American Indian and Alaska Native peoples with more comprehensive and culturally appropriate prevention treatment practices. Tribes and frontline healthcare providers understand what cultural elements may work best as protective factors. Tribes have a long history of healing people with their own wisdom and knowledge. Combining this knowledge with Western knowledge gives our people a more holistic method of care, an increase in the benefits of a program, and a higher likelihood of success.

 

For more information about successful programs that have incorporated culture, visit one of the following AI/AN specific websites:

 

Indian Health Service

National Indian Health Board

One Sky Center



[i] Foundations for a Good Practices Approach for Aboriginal Organizations in Canada: Integration of STI Prevention Education with HIV/AIDS and Addictions Programs. (2004). Retrieved from Canadian Aboriginal AIDS Network website: http://caan.ca/wp-content/uploads/2010/03/CAAN-Best-Practices-Manual.pdf
[ii] Thoms, J. M. (2007). Leading an Extraordinary Life: Wise Practices for an HIV Prevention Campaign with Two-Spirit Men. Retrieved from Two-Spirited People of the First Nations website: http://2spirits.com/PDFolder/Extraodinarylives.pdf

TEC Spotlight: Alaska Native Epidemiology Center

The Alaska Native Tribal Health Consortium's (ANTHC) Alaska Native Epidemiology Center (ANEC) is Alaska's only Tribal epidemiology center serving Alaska Native people across the state. ANEC's mission is "to contribute to the wellness of Alaska Native and American Indian people by monitoring and reporting on health data, providing technical assistance and supporting initiatives that promote health." ANEC has close working relationships with regional Tribal health organizations (THOs), Alaska Native Health Board, State of Alaska Department of Health and Social Services, University of Alaska, Centers for Disease Control Arctic Investigations Program, as well as with other Tribal and non-profit, health-related organizations. ANEC is organized across four functional units: 1) Data Dissemination and Translation; 2) Technical Assistance and Training; 3) Surveillance and Applied Epidemiology Studies; and 4) Disease Control and Prevention Programs.  

 

Within the Data Dissemination and Translation Unit, ANEC creates and distributes various health related reports including Regional Health Profiles and Factsheets, the Alaska Native Health Status Report, and the Alaska Native Injury Atlas: An Update, available on the ANEC website. Within the Technical Assistance and Training Unit, ANEC provides assistance and trainings in the areas of program evaluation, data analysis, and survey methodology. In addition, ANEC has sponsored internships and mentorships to facilitate pathways for Alaska Native and American Indian (AN/AI) students into public health. Within the Surveillance and Applied Epidemiology Studies Unit, ANEC maintains the National Cancer Institute's SEER Alaska Native Tumor Registry (ANTR), including monitoring the leading cause of mortality among AN/AI people - cancer. Lastly, within the Disease Control and Prevention Unit, ANEC's Wellness Strategies for Health program works to reduce heart disease, stroke and diabetes and their associated risk factors, the Healthy Native Families program works to reduce intimate partner and sexual violence, and the Colorectal Cancer Prevention and Control

program works to increase colorectal cancer screening.

 

Polyp people at Anchorage's Fur Rendezvous Winter Festival
Based on review of data from the Alaska Native Tumor Registry going back to 1969, colorectal cancer (CRC) was identified as a significant contributor to Alaska Native cancer incidence and mortality. Alaska Native people experience nearly two times the incidence and mortality due to colorectal cancer (CRC) as U.S. Whites. However, screening can prevent this cancer or catch it early when it's highly treatable. Starting in the mid-2000s, ANEC has worked with the Centers for Disease Control (CDC) and Indian Health Service to implement a number of CRC prevention projects. These includecreation of a flexible sigmoidoscopy training program for rural mid-level providers; the provision of itinerant endoscopy services at rural Tribal health facilities; and the creation and use of a CRC first-degree relative database to identify and screen family members of CRC patients.

 

In 2009, ANEC received funding to join CDC's CRC Control Program (CRCCP).ANTHC is one of only four Tribal organizations participating in the CRCCP. The goal of the ANEC CRCCP is to increase CRC screening among Alaska Native and American Indian people living in Alaska through policy and systems level improvements, provider education, community outreach and education, and the provision of direct screening services. Activities have included training and establishing CRC screening patient navigators statewide and assisting with improvement of electronic health record reminder systems. The ANEC CRCCP has also led numerous provider education sessions, and used a variety of methods to engage community members in screening, from giant inflatable walk-through colons, to "Polyp People" in costume at community events, to creation of Alaska Native-specific health education materials. Lastly, the ANEC CRCCP has established formal partnerships with eight regional Tribal health organizations to increase screening service delivery throughout Alaska.

 

ANTHC Patient Navigators
As a result of these efforts, there have been many successes regarding CRC prevention. These include multiple policy and systems changes around Alaska, sizable increases in screening rates, and significant decreases in CRC incidence and mortality. Systems and policy changes have included greater use of patient navigators at regional THOs to encourage screening, as well as improvements in access to CRC screening and different methods available statewide. CRC screening has doubled among Alaska Native people over the last ten years, and 2012 BRFSS data show that Alaska Native people now lead the state in CRC screening rates (62.8% compared with 59.5% of Alaskans overall). CRC has moved from being the leading cause of new cases of cancer to the second leading cause of new cases of cancer. Furthermore, there were significant annual declines of 2.6% in CRC incidence among Alaskan Native men and women from 1999-2011, in contrast to the significant increases of 1.6% annually from 1970 to 1999.

 

ANEC has been a leader in promoting CRC prevention and control among the Alaska Native population. These efforts are just part of ANEC's work to develop innovative programs, conduct rigorous data collection and analysis, train future public health leaders, and assist regional THOs to improve the health and wellness of Alaska Native people statewide.

PrEP and its Potential to Prevent HIV Infection
Michaela Gray, MPH

As new HIV infections continue to rise among American Indians, Alaska Native, and Native Hawaiians, there is a continuous push to broaden and deepen our prevention efforts.  Pre-exposure prophylaxis (or PrEP) is a highly effective prevention method that has recently started to gain popularity among prevention programs in the United States.  According to the Centers for Disease Control and Prevention (CDC), the goal of PrEP is to prevent HIV transmission should a person not living with the virus be exposed to the HIV virus.2 HIV negative individuals who are on PrEP take a pill every day, as directed by their physician.  The initial study results on the human effectiveness of PrEP were released in 2010, and follow-up studies continue to demonstrate effectiveness.  When taken consistently, PrEP has been shown to reduce the risk of acquiring an HIV infection up to 92% in people at high risk.1 In addition, PrEP can be combined with consistent condom use and other prevention methods to provide high risk populations greater protection from HIV infection.1
 

Efforts have been undertaken to raise the public's awareness of PrEP, and these efforts are now translating into community uptake.  However, questions still remain about the nature of PrEP and how to access it - especially in Indian Country, where some of the mainstream educational efforts did not reach.  PrEP is an exciting and effective option and should be readily entertained by both service providers who see people at high risk and those community members who may identify with some indicators of high risk. Currently, PrEP is only recommended for those at high risk for HIV infection:1

  • Anyone maintaining an ongoing relationship with a person living with HIV
  • Anyone who is not in a monogamous relationship and recently received a non-reactive (or negative) HIV test
  • Men-who-have-sex-with-men (MSM) who engage in unprotected anal sex
  • Heterosexual men or women who engage in unprotected vaginal or anal sex
  • People who have injected drugs within the last 6 months and/or share their injection equipment  

Most Indian Health Service (IHS) facilities and other Native-serving clinics are aware of this HIV prevention method.  If interested in starting PrEP, ask your health care provider to take you through the following steps: 

  1. Conduct an assessment of HIV risk to determine if PrEP is appropriate for you.2
  2. Conduct baseline physical examination and laboratory collection to determine if you are HIV negative and eligible to start PrEP.2
  3. If eligible, your health care provide can prescribe PrEP and provide you clear instructions on how often and when to take your pills and give you an overview of potential side effects you may experience.  In addition, you will also be required to return in a few weeks for evaluation and prescription refills.2   

It is important to remember that community members interested in PrEP need only ask a healthcare provider who can determine if this medication is offered by that Indian Health Service or Native-service health facility.  If not, a referral may be made to a facility that offers PrEP.  IHS has telehealth education that is available to assist a provider that may not be familiar with the medication or working with patients who are on PrEP.  Although PrEP is an effective method of HIV prevention, people on PrEP (and their partners) should continue to use condoms with sexual partners in addition to taking the PrEP medication as directed.  Many private insurance programs will cover PrEP when prescribed by a provider.  However, if insurance will not cover the use of HIV medicines for PrEP, the pharmaceutical industry has established medication assistance programs to help pay for PrEP medication and keep you free of HIV.

 

It is important that community members and providers alike remain informed of the options that are available to them to prevent the spread of HIV.  For more information regarding PrEP, feel free to contact the National Native American AIDS Prevention Center, www.nnaapc.org, or the IHS HIV/AIDS Program, www.ihs.gov/hiv

  1. Centers for Disease Control and Prevention. (2014).  Pre-exposure Prophylaxis (PrEP) for HIV Prevention.  Retrieved from http://www.cdc.gov/hiv/pdf/PrEP_fact_sheet_final.pdf.  
  2. Centers for Disease Control and Prevention.  (2015).  HIV Basics and PrEP.  Retrieved from http://www.cdc.gov/hiv/basics/prep.html
  3. Merriman-Webster Dictionary.  (2015).  Definition of Prophylaxis.  Retrieved from http://www.merriam-webster.com/dictionary/prophylaxis.  

Medicaid Enrollment Increasing Under ACA

According to a report from the Center for Medicaid and CHIP Services released on February 23, 2015, enrollment in Medicaid has reached nearly 10.8 million additional individuals as of December 24, 2014.  This represents an 18.6% increase over the average monthly enrollment for July through September of 2013, the pre-Marketplace open enrollment timeframe. 28 states, plus the District of Columbia, have provided greater access to health care coverage to uninsured low-income individuals by expanding Medicaid coverage through the Affordable Care Act (ACA). 

 

Though the reported large enrollment numbers under ACA's Medicaid Expansion is not specific to any minority group, such as American Indians and Alaska Natives, it is indicative of the greater access and opportunities to quality health care for very-low to low-income individuals.  Much of Indian Country's communities live in poverty and suffer from low unemployment rates.  These economic disparities do not have to come at the price of their health.  The option for states to expand Medicaid eligibility is a win for Tribes.

 

The CMS reports goes on to state that, "among states that had implemented the Medicaid expansion and were covering newly eligible adults in December 2014, Medicaid and CHIP enrollment rose by over 27% compared to the July-September 2013 baseline period, while states that did not expand Medicaid during the reporting period showed an increase of over 7 percent over the same period."

 

Several states with Tribes, like Montana, South Dakota, and Oklahoma, have not expanded Medicaid.  Tribal leaders and Tribal health advocates are encouraged to monitor Medicaid expansion in their respective state as it is another way for Tribal members to access health care and bring in revenue to their clinic through third-party billing. 

 

Click here for a list of the states that have and have not adopted Medicaid expansion (source Kaiser Family Foundation).