To:Honorable Ben Shelly, President of the Navajo Nation

Date:April 17, 2013

Rex Lee Jim, Vice President of the Navajo Nation

Jonathan Hale, Chairperson, Navajo Nation Council, Health, Education, and Human Services Committee

Larry Curley, Executive Director, Navajo Division of Health (NDOH)

John Hubbard, Area Director, Navajo Area Indian Health Service (NAIHS)

Douglas Peter, MD, Chief Medical Officer, NAIHS

Lisa Neel, Acting HIV/AIDS Consultant, Indian Health Service

Gayle Dine’Chacon, MD, Medical Advisor, Navajo Division of Health

MaeGilene Begay, CHR Program, NDOH

Philene Herrera, Navajo Health Education & HIV Prevention Program, NDOH

Larry Foster, Navajo Nation Social Hygiene, NDOH

Navajo Area I.H.S. and 638 HIV Coordinators

Navajo Area IHS and 638 STD Coordinators

NAIHS and 638 Clinical Directors

Melvin Harrison, Navajo AIDS Network

From:Jonathan Iralu, MD, FACP, Navajo Area Indian Health Service, Chief Clinical Consultant for Infectious Diseases

Subject: NAIHS 2012 Annual HIV/AIDS Report

Introduction

The year 2012 marked the 25th anniversary of HIV care at Navajo Area Indian Health Service facilities. The year was notable for rising high rates of new HIV cases treated at facilities on the Navajo Nation. This report summarizes NAIHS HIV epidemiology and HIV-related activities in 2012.

Epidemiology

Cumulative Cases

Since 1987, we have treated 436 cases of HIV infection at Navajo Area health care facilities, including 356 malesand 79 females (see Figure 1). The risk factor, Men Who Have Sex with Men (MSM), is still predominant, accounting for 40% of cases (see Figure 2). Of these 436 cumulative cases, 41% are living with HIV but not AIDS, 37% have AIDS, and 22% are deceased (see Figure 3). By the end of 2012, 34% were seen regularly in Navajo Area clinics, 12% were seen intermittently (less than 50% of appointments kept), 21% were inactive (not seen), 21% were known to be deceased, and 12% sought care elsewhere (see Figure 4).

New Cases

Here is a plot of new Navajo Area HIV cases over the last 13 years:

In 2012,forty seven (47) new cases were diagnosed on Navajo, yielding an incidence rate of 19per 100,000 per year. This is a 20% increase from 2011, when there were a total of 39 cases andan incidence rate of 15.73 per 100,000 per year. The new case rate has increased almost five-fold since 1999. Thirty two of these 47 cases were new diagnoses in 2011. Of these cases, there were 15individuals who knew their diagnosis previously but were seen for the first time in 2012 at Navajo Area facilities. Forty one (41), or 87% of the new patients were male and 6 patients, or 13%, were female (see Figure 5). The average age was 39.3 years.

Among these new cases, MSM was the predominant risk factor in 2012, making up 39% of the total(see Figure 6). The Navajo Area facility which diagnosed the most cases was Gallup (see Figure 7). By the end of 2012,77% of these new cases were living with HIV but not AIDS, 21% had AIDS, and 2% were deceased (see Figure 8). By the end of the year, 74% were active cases who kept more than half of their appointments, 13%were intermittent keeping less than half of their appointments, 4% were recently diagnosed but known to go elsewhere, and 9% were diagnosed but not yet entered into care (see Figure 9).

The mean CD4 count among new cases was 461, a dramatic increase fromthe 2011 mean of 340, reflecting improved success in diagnosing cases early in their disease through increased screening efforts. By the end of 2012, only 14% had an undetectable HIV viral load, compared with 12% last year (undetectable HIV viral load indicates optimal control of the virus by antiretroviral medications). Excellent adherence to medication regimens was noted in 68% of the new patients in 2012, an improvement from 61% last year (see Figure 10). Forty percent of the new patients were recognized as abusing alcohol during 2012. Seventeen percent of the patients in 2012 were diagnosed with depression.

Current Cases

Two hundred and four (204)HIV/AIDS patients were seen in Navajo Area clinics in 2012. This includes patients who were active in follow-up (kept 50% of appointments) and intermittent (kept <50% of appointments). There were 45 women, or 22%, and 158 men, or 77%, in this cohort and their mean age was 43.3 years (see figure 11). The MSM and heterosexual categories were again the two most important risk factors in 2012,with MSM accounting for half of the cases seen and heterosexual patients for 36% (see Figure 12). The majority of the patients were from the Gallup Service Unit, with the rest spread out evenly among other Navajo Area service units (see Figure 13). At the end of 2012, 46% were living with HIV, but not AIDS, 52% had AIDS, and 2% were deceased (see Figure 14).

The health of the current cases was good, in part explained by good adherence with clinic follow-up and treatment. The mean CD4 count was 50 points higher this year, at 426 cells/mm3. Because of treatment, 54% of the patients had an undetectable viral load, compared to 55% last year. Four (4)patients with opportunistic infections were diagnosed in 2012,including 3 cases of Pneumocystis Pneumonia (PCP) and one case of candida esophagitis (see Figure 15). There was one new malignancy but this was not HIV related. There were no HIV-positive pregnancies in 2012. One hundred forty four (144) patients were seen at the HIV clinic at Gallup Indian Medical Center in 2012. The adherence level of the current cases is shown in Figure 16.

Routine health care maintenance for the Active and Intermittent patients was much improved this year. Eighty one percent (81%) had been appropriately vaccinated for pneumococcal pneumonia and 70% completed 3 hepatitis B vaccines. Fourteen of the patients had a positive hepatitis C serology and 80% of patients had been screened for this virusin 2012. Ten of the patients had a positive PPD or Interferon Gamma Release Assay for tuberculosis. Ten of the patients had a positive serologic test for syphilis (see Figure 17).

The 204 current cases suffered significantly from mental illness and substance abuse (see Figure 18). Of great concern again, about half of the current patients abuse alcohol. Depression affected one quarter of the patients in 2012. Methamphetamine abuse was noted in 6% and injection drug use was noted in 6% as well.

There were five deaths in 2012 on Navajo among HIV infected patients, which represented a mortality rate of 2.45/100 patient years (compared to 2.40/100 patient years in 2011). One death was attributed entirely to alcohol abuse. Three patients died of AIDS-related infections (2 patients had Mycobacterium avium infection and one had Pneumocystis jiroveci infection). An intoxicated 38 year old woman died after being hit by a vehicle and a 24 year old man committed suicide by hanging.

Epidemiology Summary

The number of new cases has risen nearly 5 times higher than in 1999.

Men who have sex with menhave the highest risk for HIV acquisition but heterosexual transmission is still an important factor.

Women made up only13% of the newly diagnosed patients in 2012, a decrease from 2011.

Over half of the new cases were diagnosed in Gallup Service Unit but HIV is still being diagnosed across the Navajo Nation.

New cases are being diagnosed earlierthan ever when they have a higher CD4 count and therefore a more intact immune system. This clearly reflects more aggressive screening practices in I.H.S. and 638 sites.

Current cases are getting excellent care at all 8 Navajo Area Service Units with 54% demonstrating an undetectable viral load by the end of the year, indicating good health.

The death rate from HIV remains lowin 2012 suggesting our care is improving.

Alcohol abuse affects almost half of the current patients who received care in 2012 in our clinics and hospitals. It is clearly linked to poor outcomes in our ID clinic in Gallup.

2012 HIV Care Program Activities

Gallup Indian Medical Center (GIMC) Special ID Clinic:

The HIV clinic at Gallup Indian Medical Center (GIMC) served 144 patients in 2012, compared to 118 patients in 2011. The HIV clinic has 2 physicians, an HIV nurse specialist, 4 pharmacists, a psychology nurse specialist, and a nutritionist on the team. A Navajo medicine man joined the treatment team early in 2012 and this has allowed us to reach out to traditional Navajo patients in an innovative and culturally appropriate way.

In June 2012,the first HIV Health Technician on Navajo was hired to engage with patients in their own homes and improve treatment adherence. We have already seen an improvement in HIV viral load and CD4 count in the first 5 enrolled patients. A number of flip charts were developed for home HIV education for use by the HIV health technician and the rest of the HIV team. Monthly meetings continue with the Navajo AIDS Network and New Mexico AIDS Services to enhance patient care through case management. Quarterly meetings with the Navajo Nation HIV Prevention programare also held to enhance HIV screening rates and decrease HIV stigma.

Four Corners Project:

We continue to collaborate with NanizhoozhiCenter, Inc. (NCI), the Navajo Nation, and the University of New Mexico (UNM) in improving HIV screening among substance abusers and improving HIV care to HIV positive substance abusers. This collaboration has resulted in rapid referrals for HIV care for newly diagnosed HIV cases. The program has also enhanced HIV transmission awareness among the alcoholics seen at NCI. The funding for this program came to an end in 2012, but we hope to continue collaboration.

Minority AIDS Initiative (MAI) Grant

The Navajo Area Indian Health Service received a grant from the Minority AIDS Initiative (MAI) grant again in 2012 for $250,000 to improve patient care in the Gallup HIV clinic and increase testing rates. The grant specifically funds an HIV Nurse Specialist to do nurse case management and outreach to HIV infected patients. The intervention includes travel to patients’ homes on the Navajo Nation, training for the nurse and other clinic staff and Information Technology support. This project has had a tremendous impact on HIV care in Gallup and the surrounding service units. Plansare to expand to two HIV health technicians in Gallup and to place one health technician in Fort Defiance, Chinle and Shiprock in 2013 if the MAI funding grant application is successful. The MAI funds have also been utilized to enhance screening rates in the Gallup Service Unit. Numerousrapid HIV tests were conducted at GIMC in 2012 by expanding capability to the Urgent Care Clinic, Emergency room, and Women’s Health unit. A total of seven rapid tests have been positive since the inception of this program.

Movie theater advertisements continued to be featured at the local theaters in 2012. In 2013, we plan to run advertisements on buses and billboards across the Navajo Nation to get out the HIV screening message. In addition, placing an HIV screening advertisement on Facebook in 2013 is also planned.

Prevention Efforts:

A strong STD and HIV prevention campaign in the Navajo Area continues to be active. Gallup Indian Medical Center continues to provide free condoms to a major bar in downtown Gallup. There is ongoing collaboration with the Navajo Nation, CDC, and the states of New Mexico, Arizona, and Utah STD programs to eliminate syphilis on the reservation. We continue to see syphilis cases in McKinley and San Juan Counties linked in part topatients meeting sexual partners through internet social networking. We intend to let the public know about the risks through Facebook advertisement in 2013.

Screening Efforts

In 2006, the CDC put forth new recommendations encouraging the testing of every American for HIV in all clinical settings. The American College of Physicians (ACP)and the US Preventative Services Task Force (USPST) have since made a similar recommendation to the public. The Navajo Nation updated its HIV code in 2011 to mandate universal testing on Navajo at Federal and tribal health care sites. NAIHS CEOs are now required to document improvement in HIV testing at their service units as part of their annual performance reviews. We are encouraging the utilization of Electronic Health Record (HER) reminders at all Navajo Area service units to expand universal HIV screening.

Provider Education

The annual Four Corners TB and HIV program was held in Durango in October 2012. It was very well attended by IHS, state and CDC health care providersand officials. Speakers included Dr. Paul Farmer from Harvard Medical School and Dr.SonyaShin from Gallup Indian Medical Center. Especially moving was a presentation from the new HIV Health Technician from Gallup.

Conclusions and Recommendations:

HIV INFECTION RATES ARE CLIMBING DANGEROUSLY HIGH ON THE NAVAJO NATION. It is very clear that the HIV epidemic on Navajo is growing. We need to get the prevention and early screening message out in every venue, whether tribal or federal.

Alcohol abuse in 2012is still the principal barrier to HIV care and survival of Navajo people infected with HIV. We must screen alcoholics universally for HIV infection and enroll HIV-positive alcoholic patients in alcohol rehabilitation.

Universal screening for HIV is now recommended by the Centers for Disease Control (CDC), ACP, and USPSTF as well as being mandated by the Navajo Nation tribal government. Every effort should be made to offer HIV testing to every Navajo patient seen at IHS and 638 facilities, as advocated under the new tribal HIV code. HIV screening needs to be offered to every primary care patient and every admitted patient in 2013 at IHS and tribal sites.

The year 2013 is the year to work to decrease anti-HIV stigma in communities on Navajo. This will require a culturally sensitive, Navajo-specific publicity campaign in collaboration between the Navajo Nation HIV Prevention Office, the Navajo AIDS Network, and the Navajo Area Indian Health Service.