This is the accessible text file for GAO report number GAO-08-90 
entitled 'Indian Health Service: HIV/AIDs Prevention and Treatment 
Services for American Indians and Alaska Natives' which was released on 
December 13, 2007. 

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Report to Congressional Requesters: 

United States Government Accountability Office: 

GAO: 

December 2007: 

Indian Health Service: 

HIV/AIDS Prevention and Treatment Services for American Indians and 
Alaska Natives: 

Indian Health Service: 

GAO-08-90: 

GAO Highlights: 

Highlights of GAO-08-90, a report to congressional requesters. 

Why GAO Did This Study: 

American Indians and Alaska Natives have the third highest rate of 
HIV/AIDS diagnosis in the United States. They are also more likely than 
individuals with HIV/AIDS from other racial and ethnic groups to 
receive treatment at later stages of the disease and have shorter life 
spans. 

The Indian Health Service (IHS), located within the Department of 
Health and Human Services (HHS), provides health care services, 
including HIV/AIDS treatment, to eligible American Indians and Alaska 
Natives. IHS patients with HIV/AIDS may also receive care through other 
sources depending on their access to private health insurance or their 
eligibility for other federal health care programs, such as Medicare 
and Medicaid. 

GAO examined the extent to which IHS provided (1) HIV/AIDS prevention 
services and (2) HIV/AIDS treatment services. GAO also examined (3) 
what other HIV/AIDS-related initiatives IHS has undertaken. GAO 
reviewed documents and interviewed officials from IHS headquarters, 
area offices, and IHS-funded facilities, as well as advocacy groups. We 
also conducted site visits in two IHS areas. 

What GAO Found: 

HIV/AIDS prevention services were generally available from IHS, but 
these services varied across the 12 IHS areas. HIV/AIDS education was 
provided in all areas in a variety of settings, such as IHS-funded 
facilities, schools, and health fairs. In addition to education, IHS 
offered HIV testing services in all areas; however, the type and extent 
of services varied. In addition, some IHS officials described other 
services that were provided as part of their HIV/AIDS prevention 
activities, such as condom distribution. 

According to IHS officials, HIV/AIDS treatment services, while offered 
at some IHS facilities, were generally received outside of IHS. Five 
IHS-funded hospitals, such as the Phoenix Indian Medical Center in 
Arizona, regularly treated patients. Although some other IHS facilities 
provided limited treatment services, most relied on outside providers. 
For example, IHS patients with HIV/AIDS might see a specialist outside 
of IHS every 3 months for their HIV/AIDS treatment services and an IHS 
provider for other routine care. IHS officials reported that most IHS 
facilities did not provide treatment services because they had few 
American Indian or Alaska Native patients known to have HIV/AIDS, had 
limited resources, focused on other health concerns, or their providers 
had limited training or experience treating the disease. Additionally, 
some patients may not access or continue treatment from IHS or outside 
providers due to concerns about confidentiality and lack of 
transportation to distant facilities. 

IHS has undertaken outreach and planning, capacity building, and 
surveillance initiatives related to HIV/AIDS. These initiatives are 
overseen by national and area-level IHS officials. The outreach and 
planning initiatives include an HIV/AIDS Web site and the development 
of a national HIV/AIDS administrative work plan. IHS has also 
undertaken several initiatives aimed at building the capacity of 
providers to offer HIV/AIDS-related prevention and treatment services, 
such as training of health care providers and implementation of an 
HIV/AIDS-related data system that can send providers reminders when 
patients with HIV/AIDS need care. Finally, IHS has undertaken 
initiatives related to improving the surveillance of HIV/AIDS in the 
American Indian and Alaska Native population by developing a prenatal 
HIV screening measure and an early detection surveillance system. 

GAO received written comments from HHS on a draft of this report. HHS 
substantially agreed with the findings of this report. HHS also offered 
technical comments to provide additional information or clarify 
specific findings, which we incorporated as appropriate. 

To view the full product, including the scope and methodology, click on 
[hyperlink, http://www.GAO-08-90]. For more information, contact Laurie 
Ekstrand at (202) 512-7114 or ekstrandl@gao.gov 

[End of section] 

Contents: 

Letter: 

Results in Brief: 

Background: 

IHS HIV/AIDS Prevention Services Generally Were Available, but Varied 
Across Areas: 

Some IHS Facilities Provided HIV/AIDS Treatment Services, but Most 
American Indians and Alaska Natives Received Services from Outside 
Providers for a Variety of Reasons: 

IHS Has HIV/AIDS Outreach and Planning, Capacity Building, and 
Surveillance Initiatives: 

Agency Comments and Our Evaluation: 

Appendix I: Reasons Why Treatment Services May Not Be Offered or 
Accessed, as Reported by IHS Area Officials: 

Appendix II: Comments from the Indian Health Service: 

Appendix III: GAO Contact and Staff Acknowledgments: 

Related GAO Products: 

Tables: 

Table 1: IHS User Population by IHS Area: 

Table 2: Estimated Number of American Indians and Alaska Natives Living 
with AIDS, by IHS Area: 

Figure: 

Figure 1: Counties in the 12 IHS Areas: 

Abbreviations: 

CARE Act: Ryan White Comprehensive AIDS Resources Emergency Act of 
1990: 

CDC: Centers for Disease Control and Prevention: 

HAART: Highly Active Antiretroviral Therapy: 

HHS: Department of Health and Human Services: 

HMS: HIV Management System: 

HRSA: Health Resources and Services Administration: 

IHS: Indian Health Service: 

SAMHSA: Substance Abuse and Mental Health Services Administration: 

UIHP: Urban Indian Health Program: 

United States Government Accountability Office: 

Washington, DC 20548: 

December 14, 2007: 

The Honorable Byron Dorgan: 
Chairman: 
Committee on Indian Affairs: 
United States Senate: 

The Honorable John McCain: 
United States Senate: 

The Honorable Jeff Bingaman: 
United States Senate: 

Although they represent less than 1 percent of all HIV/AIDS reported 
cases, American Indians and Alaska Natives had the third highest rate 
of HIV/AIDS diagnosis in the United States after blacks and Hispanics 
in 2005.[Footnote 1] According to the Centers for Disease Control and 
Prevention (CDC), an agency within the Department of Health and Human 
Services (HHS), since the beginning of the epidemic through 2005, a 
cumulative total of 3,238 American Indians and Alaska Natives have been 
diagnosed with AIDS.[Footnote 2] But this estimate may be understated 
because American Indians and Alaska Natives, particularly those living 
in rural areas, may be less likely to be tested. They may also be less 
likely to seek testing because of concerns about confidentiality when 
living in close-knit communities.[Footnote 3] Additionally, CDC and 
others have reported that American Indians and Alaska Natives are more 
likely to receive treatment at later stages of the disease and have 
shorter life spans compared to most other population groups with HIV/ 
AIDS. Furthermore, American Indians and Alaska Natives experience 
disproportionately high rates of risk factors for HIV/AIDS, such as 
sexually transmitted infections, substance abuse, and poor 
socioeconomic conditions. For example, individuals who are under the 
influence of alcohol or drugs are more likely to engage in high-risk 
behavior that can put them at greater risk for contracting or spreading 
HIV/AIDS. 

The Indian Health Service (IHS), part of HHS, provides or arranges 
health care services, including HIV/AIDS treatment, to eligible 
American Indians and Alaska Natives.[Footnote 4] It provided or 
arranged services for a projected 1.5 million American Indians and 
Alaska Natives in fiscal year 2007, across 12 federally designated 
areas that cover all or part of 35 states. Services are provided 
through IHS-funded facilities, including those operated by IHS, those 
operated by tribes, and Urban Indian Health Program (UIHP) facilities 
or through contracts with outside providers.[Footnote 5] Our prior work 
found gaps in the health care services IHS provided for American 
Indians and Alaska Natives that, in some cases, hindered American 
Indians and Alaska Natives from obtaining needed services.[Footnote 6] 
In addition to IHS, American Indians and Alaska Natives with HIV/AIDS 
may also receive care through other sources depending on their access 
to private health insurance; their eligibility for other federal health 
care programs, such as Medicare and Medicaid; or their eligibility for 
services provided by entities funded through Ryan White Comprehensive 
AIDS Resources Emergency (CARE) Act of 1990 grants.[Footnote 7] 

Because access to HIV/AIDS prevention services can affect the number of 
American Indians and Alaska Natives who have the disease and there may 
be variation in the availability of treatment services, you asked us to 
examine IHS's efforts related to HIV/AIDS. Specifically, we examined 
the extent to which IHS provides (1) HIV/AIDS prevention services and 
(2) HIV/AIDS treatment services. We also examined (3) what other HIV/ 
AIDS-related initiatives IHS has undertaken. 

To examine the extent to which IHS provides HIV/AIDS prevention 
services, we interviewed the officials identified by IHS as the most 
knowledgeable about HIV/AIDS services in each of the 12 area offices. 
The area officials provided varying levels of detail about the IHS- 
funded HIV/AIDS prevention services provided by the tribes in their 
area, including those provided at tribally operated facilities. For 
example, 3 areas included officials from tribal organizations in these 
interviews, while other area officials said they had limited knowledge 
of the HIV/AIDS prevention services that were provided at tribally 
operated facilities. In addition to the interviews, we also reviewed 
available IHS documentation and interviewed relevant IHS officials 
about IHS's budget, data systems, and HIV/AIDS prevention services. In 
addition, we reviewed data from CDC and HHS's Health Resources and 
Services Administration (HRSA) relevant to American Indians and Alaska 
Natives with HIV/AIDS. Finally, we interviewed representatives from 
advocacy organizations, such as the National Alliance of State & 
Territorial AIDS Directors, the National Council of Urban Indian 
Health, the National Indian Health Board, and the National Native 
American AIDS Prevention Center. We also visited 2 IHS areas, Phoenix 
and Tucson, to interview officials from IHS-funded facilities, tribal 
health departments, and Ryan White-funded facilities that served 
American Indians and Alaska Natives. We selected the Phoenix area in 
order to interview officials at the Phoenix Indian Medical Center, 
which has the IHS HIV Center of Excellence. In addition, the state of 
Arizona has the third largest population of American Indians and Alaska 
Natives and the Phoenix area has the second highest number of American 
Indians and Alaska Natives living with HIV/AIDS. Because of the Tucson 
area's close proximity to the Phoenix area and the expectation that 
there would be some variation in the availability of HIV/AIDS services 
for American Indians and Alaska Natives in the same state, we also 
visited Tucson. 

To examine the extent to which IHS provides HIV/AIDS treatment 
services, we generally conducted the same activities that we used to 
examine prevention services. Most of the area officials were able to 
provide detailed information about the HIV/AIDS services for American 
Indians and Alaska Natives in their area. We conducted additional 
interviews with HIV/AIDS service providers both within and outside of 
IHS in three areas: Albuquerque, in order to gain additional 
information about the HIV/AIDS services in Colorado; Nashville, because 
the area provides services in parts of 14 states; and Phoenix, in order 
to gain additional information about HIV/AIDS services in Nevada. For 
example, we interviewed IHS physicians with experience treating 
patients with HIV/AIDS and staff at IHS-funded facilities and Ryan 
White-funded facilities that treated American Indians and Alaska 
Natives patients with HIV/AIDS. IHS officials and representatives from 
the National Native American AIDS Prevention Center helped us to 
identify these providers. In addition, we used data from HRSA, which 
administers the Ryan White program, in order to identify Ryan White- 
funded facilities that provided services to American Indians and Alaska 
Natives. 

To examine what other HIV/AIDS-related initiatives IHS has undertaken, 
we reviewed relevant IHS documents and data on HIV/AIDS. We also 
interviewed IHS headquarters officials and those in the area offices 
knowledgeable about IHS's HIV/AIDS-related initiatives. 

The information presented in this report is intended to provide a 
general description of HIV/AIDS prevention and treatment services 
available to American Indians and Alaska Natives through IHS. IHS does 
not routinely collect data or create reports on HIV/AIDS and generally 
cannot track spending or services provided specifically for HIV/AIDS. 
Moreover, tribes generally are not required to report detailed 
information to IHS about the health services they provide or facilities 
they operate using IHS funds.[Footnote 8] Due to these data 
limitations, we relied on interviews with the area offices. For each 
interview, we used a 21-item question set that contained open-ended 
questions. The area officials we interviewed provided varying levels of 
detail to answer our questions, with six conducting brief surveys of 
some of the facilities in their areas to provide information for GAO, 
while others relied on their general knowledge. Because our questions 
were open-ended, we cannot be sure that officials provided a complete 
list of all services or activities they provide. Thus our information 
from these interviews is illustrative only. We did not independently 
validate the information provided by the area offices or contained in 
documents obtained from IHS officials. However, we discussed any 
questions we had about the information we received with the officials. 
We conducted our work from September 2006 through November 2007 in 
accordance with generally accepted government auditing standards. 

Results in Brief: 

Although HIV/AIDS prevention services were generally available from 
IHS, these services varied across the 12 IHS areas. HIV/AIDS education 
was provided in all areas in a variety of settings, such as IHS-funded 
facilities, schools, health fairs, and prisons. For example, two tribal 
health educators said that they play a quiz show about HIV with youth. 
In addition to education, IHS offered HIV testing services in all 
areas; however, the type and extent of services varied. IHS officials 
reported that HIV testing was offered primarily to pregnant women and 
those at high risk for HIV/AIDS. In addition, some IHS area officials 
described other services that were provided as part of their HIV/AIDS 
prevention activities, including partner notification and condom 
distribution. 

While some IHS facilities provided HIV/AIDS treatment services, area 
officials reported that most American Indians and Alaska Natives with 
HIV/AIDS received services outside of IHS. Five IHS-funded hospitals 
regularly treated patients and had staff dedicated to providing HIV/ 
AIDS treatment. For example, the Phoenix Indian Medical Center had 
staff such as a physician experienced in treating HIV/AIDS and an HIV 
clinical pharmacist providing HIV/AIDS treatment services. Although 
some other IHS facilities provided limited treatment services, most IHS 
facilities relied on outside providers to deliver treatment services. 
For example, IHS patients with HIV/AIDS might see a specialist outside 
of IHS quarterly for their HIV/AIDS treatment services and an IHS 
provider for other health care needs. Area officials reported that most 
IHS facilities did not provide treatment services because they had few 
American Indian and Alaska Native patients known to have HIV/AIDS, had 
limited resources, focused on other health concerns, or their providers 
had limited training or experience treating the disease. Additionally, 
some patients may not access or continue treatment from IHS or outside 
providers for reasons such as concerns about others learning of their 
HIV status or lack of transportation to distant facilities. 

IHS has undertaken outreach and planning, capacity building, and 
surveillance initiatives related to HIV/AIDS, which are overseen by 
national and area-level officials. IHS's outreach and planning 
initiatives include an HIV/AIDS program Web site; an HIV listserv, 
which e-mails information to those working with American Indians and 
Alaska Natives with HIV/AIDS; and a national HIV/AIDS administrative 
work plan. IHS also has carried out several initiatives aimed at 
building the capacity of providers to offer HIV/AIDS-related prevention 
and treatment services, such as training of health care providers and 
implementation of an HIV/AIDS-related data system, which can send 
providers reminders when patients with HIV/AIDS need care. 
Additionally, IHS has undertaken initiatives related to improving the 
surveillance of HIV/AIDS in the American Indian and Alaska Native 
populations by developing a prenatal HIV screening measure and an early 
detection surveillance system. 

Background: 

For fiscal year 2007, IHS projected a user population[Footnote 9] of 
about 1.5 million individuals, or about 35 percent of the population 
who identified themselves as American Indian or Alaska Native in the 
2000 U.S. Census.[Footnote 10] Not all persons self-identifying as 
American Indians and Alaska Natives in the U.S. Census are members of 
federally recognized tribes or descendents of such members; therefore 
they are not all eligible for IHS services. However, more than half of 
the federally recognized American Indian and Alaska Native population 
does not permanently reside on a reservation and therefore may have 
limited or no access to IHS services because of their distance from IHS-
funded facilities. 

In addition to its headquarters in Rockville, Maryland, IHS consists of 
a system of IHS-funded facilities organized into 12 geographic areas of 
various sizes and containing different types of facilities. Each of the 
12 areas has an area office, an administrative body that may include an 
area director, a chief medical officer, and other staff who oversee the 
area's budget and programs. See figure 1 for a map of the counties 
included in the 12 IHS areas. These facilities are IHS-operated, 
tribally operated, or overseen by the UIHP.[Footnote 11] IHS areas 
include more than 650 of these IHS-funded health care facilities, 
including hospitals, health centers, health stations, and UIHP 
facilities. These facilities mainly offer primary care to small, rural 
populations, with a limited number of larger health care facilities 
providing specialty care, such as treatment of HIV/AIDS. The types of 
facilities in each area vary. For example, the California area has no 
IHS-funded hospitals, while the Aberdeen area has nine small hospitals. 
The estimated IHS user population in each of the 12 areas ranges from 
about 24,000 to about 310,000 (see table 1). 

Figure 1: Counties in the 12 IHS Areas: 

This figure is a map of counties in the 12 IHS areas. 

[See PDF for image] 

Source: GAO-05-789 and GAO analysis of additional IHS information, as 
of June 2007. 

Note: Some counties are included in more than one IHS area. This occurs 
in the IHS areas of Albuquerque, California, Navajo, Phoenix, and 
Tucson. 

[End of figure] 

Table 1: IHS User Population by IHS Area: 

IHS area: Aberdeen; 
Estimated IHS area user population, 2006: 118,347. 

IHS area: Alaska; 
Estimated IHS area user population, 2006: 130,682. 

IHS area: Albuquerque; 
Estimated IHS area user population, 2006: 86,504. 

IHS area: Bemidji; 
Estimated IHS area user population, 2006: 98,825. 

IHS area: Billings; 
Estimated IHS area user population, 2006: 70,384. 

IHS area: California; 
Estimated IHS area user population, 2006: 74,248. 

IHS area: Nashville; 
Estimated IHS area user population, 2006: 47,379. 

IHS area: Navajo; 
Estimated IHS area user population, 2006: 236,893. 

IHS area: Oklahoma City; 
Estimated IHS area user population, 2006: 309,542. 

IHS area: Phoenix; 
Estimated IHS area user population, 2006: 150,886. 

IHS area: Portland; 
Estimated IHS area user population, 2006: 100,395. 

IHS area: Tucson; 
Estimated IHS area user population, 2006: 24,164. 

Source: IHS. 

[End of table] 

For fiscal year 2006, Congress appropriated approximately $2.7 billion 
to IHS to primarily provide direct care at IHS-funded facilities and to 
purchase care outside of IHS through contracts.[Footnote 12] From this 
appropriation, IHS also funds public health nursing, health education, 
and other functions. In addition, in fiscal year 2006, IHS received 
reimbursements of $681 million from Medicare, Medicaid, and private 
health insurance, with Medicare and Medicaid contributing almost 90 
percent of those reimbursements. These reimbursements were for 
treatment at IHS-funded facilities of patients who were eligible for 
Medicare and Medicaid, in addition to IHS health care.[Footnote 13] 
More than 50 percent of IHS's budget supports tribally operated 
facilities and around 1 percent supports UIHP facilities. Out of the 
total appropriated for services, approximately $500 million was 
designated for contract health services.[Footnote 14] For services that 
IHS-funded facilities cannot provide, the contract health services 
funding is used to purchase care for eligible American Indians and 
Alaska Natives through contracts with outside providers.[Footnote 15] 
For example, contract health services money has been used to purchase 
specialty care that may not be available at a patient's local IHS- 
funded facility, such as behavioral health care. While IHS tracks the 
overall costs of providing health services, it does not itemize those 
costs by disease; therefore the agency does not track the cost for its 
facilities to provide HIV/AIDS prevention and treatment services. 

HIV/AIDS Prevention Strategies: 

According to HHS, efforts are under way--primarily by CDC--to fund 
prevention programs to educate people at highest risk, as well as the 
general public, about HIV/AIDS and preventing or reducing their risk. 
CDC reports that HIV prevention programs can include strategies such as 
the following.[Footnote 16] 

HIV testing and counseling. According to CDC, individuals at risk for 
HIV should be offered testing and counseling so that they can be aware 
of their status and take steps to protect their own health and that of 
their partners. Testing is a key HIV prevention strategy because, as 
CDC estimates, more than half of HIV infections are transmitted by 
individuals who are unaware of their infection. Recently available HIV 
rapid test results are available the same day, in contrast to 
traditional lab-based testing that can take up to 2 weeks to provide 
results. Thus rapid testing can help ensure that individuals receive 
their test result. Moreover, because rapid tests do not require lab 
facilities or highly trained staff, this type of test can expand access 
to testing in both clinical and nonclinical settings; however, rapid 
tests are more expensive than lab-based tests. In addition to testing, 
counseling services offer patients ways to eliminate or reduce their 
risk for HIV infection. 

Partner notification. Sexual or needle-sharing partners of HIV-positive 
individuals have been exposed to HIV and may be infected. Partner 
notification services attempt to locate these individuals based on 
information provided by the patient to provide counseling, education, 
and other services to prevent infection or, if the individual is 
infected, provide referrals to care. 

Health education and risk reduction. Health education provides 
individuals with the skills and information necessary to avoid or 
reduce behaviors that put them at risk for HIV infection. Health 
education services can include individual, group, school, and community 
interventions, as well as outreach to HIV-positive individuals and HIV- 
negative individuals at high risk. These services can also include 
health communication and public information programs for individuals at 
high risk and the general public. Risk reduction activities can include 
condom distribution and needle exchange programs. 

HIV/AIDS Treatment Strategies and Barriers to Care: 

HHS issues guidelines for the medical management of HIV and issues 
surrounding HIV infection.[Footnote 17] The guideline documents are 
periodically reviewed and updated by panels of HIV experts, because 
concepts relevant to management of HIV change rapidly. The recommended 
treatment for HIV is a combination of three or more drugs, called 
Highly Active Antiretroviral Therapy (HAART). HAART is used to slow the 
progression of HIV/AIDS and has reduced the number of HIV/AIDS deaths, 
but it may have side effects and requires adherence to complicated drug 
regimens. Additionally, although these drugs can treat HIV infection, 
HIV cannot be cured. A 2004 Kaiser Family Foundation report estimated 
the annual cost for providing these drugs was between $10,000 and 
$12,000 per patient. 

Beyond drug regimens, patients with HIV/AIDS may require additional 
specialized care. According to CDC, proper management of HIV/AIDS 
involves a complex array of behavioral, psychosocial, and medical 
services, and therefore referral to a health care provider or facility 
experienced in caring for HIV-infected patients is advised. Treatment 
must be tailored to the patient's needs and may include mental health 
services, substance abuse services, and medical case management, 
including treatment adherence services. Patients with HIV/AIDS may also 
require support services, such as housing or transportation assistance. 

Patients with HIV/AIDS may face barriers to care. A 1998 study reported 
that patients with HIV/AIDS in both rural and urban areas experienced 
barriers to treatment services including a lack of knowledge about the 
disease, insufficient financial resources, and a lack of employment 
opportunities.[Footnote 18] Moreover, the study found that patients 
with HIV/AIDS in rural areas--compared to their urban counterparts-- 
reported significantly greater need to travel long distances to medical 
facilities and personnel; a shortage of adequately trained medical and 
mental health professionals; a lack of personal or public 
transportation; and community stigma toward people living with HIV. 

American Indians and Alaska Natives and HIV/AIDS: 

American Indians and Alaska Natives suffer from HIV/AIDS at higher 
rates than whites and from a range of other medical conditions at 
higher rates than the general population. CDC estimated that in 2005, a 
total of 1,581 American Indians and Alaska Natives were living with 
AIDS in the 50 states and the District of Columbia. CDC's 2005 
surveillance data also showed that of individuals diagnosed with AIDS 
from 1997 through 2004, American Indians and Alaska Natives died sooner 
after diagnosis than did individuals of all other races and ethnicities 
except blacks.[Footnote 19] In addition, women accounted for 24 percent 
of the estimated numbers of American Indians and Alaska Natives living 
with AIDS in 2005, compared with 12.5 percent for whites. The data also 
showed that the 10 states with the highest number of American Indians 
and Alaska Natives living with AIDS in 2005 were: (1) California, (2) 
Arizona, (3) Oklahoma, (4) Washington, (5) New York, (6) Alaska, (7) 
North Carolina, (8) New Mexico, (9) Minnesota, and (10) Texas.[Footnote 
20] CDC's estimate of the number of American Indians and Alaska Natives 
living with AIDS in the 12 IHS areas, which do not cover the entire 
United States, was 872 in 2005 (see table 2). 

Table 2: Estimated Number of American Indians and Alaska Natives Living 
with AIDS, by IHS Area: 

IHS area[A]: Aberdeen; 
Estimated number of American Indians and Alaska Natives living with 
AIDS, 2005[B]: 26. 

IHS area[A]: Alaska; 
Estimated number of American Indians and Alaska Natives living with 
AIDS, 2005[B]: 78. 

IHS area[A]: Albuquerque; 
Estimated number of American Indians and Alaska Natives living with 
AIDS, 2005[B]: 67. 

IHS area[A]: Bemidji; 
Estimated number of American Indians and Alaska Natives living with 
AIDS, 2005[B]: 23. 

IHS area[A]: Billings; 
Estimated number of American Indians and Alaska Natives living with 
AIDS, 2005[B]: 12. 

IHS area[A]: California; 
Estimated number of American Indians and Alaska Natives living with 
AIDS, 2005[B]: 104. 

IHS area[A]: Nashville; 
Estimated number of American Indians and Alaska Natives living with 
AIDS, 2005[B]: 56. 

IHS area[A]: Navajo; 
Estimated number of American Indians and Alaska Natives living with 
AIDS, 2005[B]: 61. 

IHS area[A]: Oklahoma City; 
Estimated number of American Indians and Alaska Natives living with 
AIDS, 2005[B]: 149. 

IHS area[A]: Phoenix; 
Estimated number of American Indians and Alaska Natives living with 
AIDS, 2005[B]: 142. 

IHS area[A]: Portland; 
Estimated number of American Indians and Alaska Natives living with 
AIDS, 2005[B]: 135. 

IHS area[A]: Tucson; 
Estimated number of American Indians and Alaska Natives living with 
AIDS, 2005[B]: 19. 

IHS area[A]: Total in IHS areas[C]; 
Estimated number of American Indians and Alaska Natives living with 
AIDS, 2005[B]: 872. 

Source: CDC. 

Notes: CDC assigned the cases of American Indians and Alaska Natives 
living with AIDS to IHS area by using county codes supplied by GAO. A 
county can only be included a single time in only one area; the 
national HIV/AIDS surveillance data cannot be analyzed at a lower 
geographic division than the county level. Therefore, CDC made some 
arbitrary decisions when counties were listed across areas. This 
occurred in the Albuquerque, California, Navajo, and Phoenix areas. 

[A] The 12 IHS areas cover all or part of 35 states. 

[B] CDC's estimated number of American Indians and Alaska Natives 
living with AIDS does not differentiate between IHS-eligible and non- 
IHS-eligible American Indians and Alaska Natives. 

[C] CDC estimated that 1,581 American Indians and Alaska Natives were 
living with AIDS in the 50 states and the District of Columbia in 2005. 

[End of table] 

HIV/AIDS is one of many health concerns facing American Indians and 
Alaska Natives. While American Indians and Alaska Natives have the 
third highest rate of HIV/AIDS after blacks and Hispanics, the disease 
is not one of the top 10 leading causes of death for this population. 
Some of the major health concerns facing the population include 
diabetes; heart, liver, and cardiovascular diseases; cancer; 
unintentional injuries; obesity; substance abuse; and suicide. Given 
these numerous health concerns, as well as challenges related to 
poverty and unemployment, the National Alliance of State & Territorial 
AIDS Directors report that making HIV/AIDS a priority is often 
difficult for many American Indian and Alaska Native communities. 

Although HIV/AIDS is not among the major health concerns for the 
population, American Indians and Alaska Natives experience high rates 
of risk factors for HIV infection, such as sexually transmitted 
diseases and poverty-related conditions. According to 2005 CDC 
surveillance data by race or ethnicity, American Indians and Alaska 
Natives had the second highest rates of gonorrhea and chlamydia and the 
third highest rate of syphilis.[Footnote 21] CDC notes that these rates 
suggest that the sexual behaviors that facilitate the spread of HIV are 
relatively common among American Indians and Alaska Natives.[Footnote 
22] In addition to sexually transmitted diseases, alcohol and drug 
abuse--which are prevalent in the American Indian and Alaska Native 
community--are risk factors for HIV transmission. Moreover, conditions 
related to poverty, such as lower levels of education and poorer access 
to health care, may increase the risk for HIV infection. During 2002 
through 2004, approximately one quarter of American Indians and Alaska 
Natives about twice the national average were living in 
poverty.[Footnote 23] American Indians and Alaska Natives also have 
poorer access to health care than other racial and ethnic groups, with 
21 percent of American Indians and Alaska Natives lacking a usual 
source of medical care, compared to 18 percent of whites in 2004. 
[Footnote 24] 

Furthermore, American Indians and Alaska Natives may be less likely to 
be tested for HIV than persons of other racial and ethnic groups 
because of location and confidentiality concerns. For example, those 
who live in rural areas may be less likely to be tested for HIV because 
of limited access to testing. While access to preventive services, such 
as testing, is a problem for rural populations in general, more 
American Indians and Alaska Natives, compared with persons of other 
races and ethnicities, resided in rural areas at the time of their AIDS 
diagnosis[Footnote 25]. Also, American Indians and Alaska Natives may 
be less likely to seek testing because of concerns about 
confidentiality in close-knit communities, where someone who seeks 
testing is likely to encounter a friend, relative, or acquaintance at 
the local health care facility. 

American Indians and Alaska Natives May Access Services outside of IHS: 

Many American Indians and Alaska Natives have health insurance coverage 
and may choose to access services outside of IHS. According to IHS, 
about 55 percent of the IHS user population has some form of public or 
private coverage. Of this, about 43 percent are eligible for Medicaid 
or Medicare. Depending on their eligibility and resources, American 
Indians and Alaska Natives may have access to health care at facilities 
available to the general population, such as public or private 
hospitals and community health centers. 

For HIV/AIDS care, American Indians and Alaska Natives may also access 
services at Ryan White-funded facilities. The Ryan White Program 
provides funding to states, territories, metropolitan areas, and other 
public or private nonprofit entities to provide health care, 
medications, and support services to more than 500,000 medically 
underserved individuals and families affected by HIV or AIDS, including 
American Indians and Alaska Natives.[Footnote 26] Specifically, 
services include outpatient medical and dental care, prescription 
drugs, case management, home health care, and hospice care. 

IHS HIV/AIDS Prevention Services Generally Were Available, but Varied 
Across Areas: 

IHS area officials reported that HIV/AIDS prevention services were 
generally available in all 12 areas. HIV/AIDS education was available 
in every IHS area. Testing services were also available in every IHS 
area, though the type and extent of the services varied. In addition to 
education and testing services, officials in some areas mentioned that 
some facilities provided other services as part of their HIV/AIDS 
prevention activities, such as condom distribution and partner 
notification. 

HIV/AIDS Education Was Provided in All Areas: 

Officials from IHS area offices reported that HIV/AIDS education 
services were offered in all 12 areas. Education was provided by a 
variety of staff, including practitioners, such as physicians and 
nurses, during medical appointments; tribal health educators; and 
community health representatives,[Footnote 27] in various settings, 
including IHS-funded facilities, tribal health departments, schools, 
health fairs, and prisons. For example, one provider said that she held 
bingo nights at an UIHP facility, beginning the evening with an HIV 
education speaker or presentation. Two tribal health educators and an 
UIHP official said that they played quiz show games with youth to teach 
them about HIV/AIDS. 

IHS officials and tribal health educators noted that HIV/AIDS education 
materials were available; however, there were challenges with using 
these materials. Officials in four areas--Albuquerque, Oklahoma City, 
Portland, and Tucson--noted concerns with the cultural appropriateness 
of HIV/AIDS education materials. Two tribal health educators reported 
using materials from sources outside of IHS, such as the American Red 
Cross and Advocates for Youth; however, they modified their 
presentations to make them more appropriate and easy to 
understand.[Footnote 28] For example, the tribal educators mentioned 
that they modified the wording of an HIV prevention curriculum's 
activity to make it more relevant to their groups. Additionally, one 
area official said that educators had to revise the materials to a 
reading level where they could be understood by the target audience. 
Despite these education efforts, some IHS officials and advocacy groups 
noted that misconceptions about HIV/AIDS remained among some in the 
American Indian and Alaska Native community--for example, that the 
disease could be contracted from a toilet seat or that only men who 
have sex with men could become infected. 

Some HIV Testing Services Were Available in All Areas, but Type and 
Extent of Services Varied: 

According to IHS officials and service providers, HIV testing services 
were offered in all 12 IHS areas, but some officials said that services 
were not available at all facilities. Additionally, the type of testing 
that was available varied. IHS officials reported that HIV testing was 
offered primarily to pregnant women and those at high risk for HIV/ 
AIDS. IHS HIV testing services included both lab-based and rapid tests, 
with officials in 9 IHS areas--Aberdeen, Alaska, Albuquerque, Billings, 
California, Nashville, Oklahoma City, Phoenix, and Portland--reporting 
that rapid testing was available in one or more of their facilities. 
IHS officials reported advantages to rapid testing, including the 
ability to test pregnant women who were in labor or patients presenting 
in emergency rooms, and to provide quick results to patients at high 
risk who are unlikely to return to the facility to receive the results 
from lab-based tests. Officials in three areas--Aberdeen, Phoenix, and 
Tucson--reported that some patients do not return to pick up their lab- 
based HIV test results. However, some IHS officials reported that cost 
was a barrier to adopting the more expensive rapid testing and that 
staff required additional training to administer the tests. To address 
this concern, one area reported providing funding for training on rapid 
HIV testing for clinical staff. 

Although testing services were available to some extent in all areas, 
some IHS officials and advocacy groups expressed concern that some 
American Indians and Alaska Natives were not being tested for HIV. 
Officials in one area reported that some IHS health care providers may 
not feel comfortable discussing sexuality, and as a result they may not 
offer testing to patients in groups at high risk. An official in 
another area reported that, given more prevalent health concerns, 
providers did not always discuss HIV/AIDS. An official in a third area 
said that, while IHS-funded facilities offer testing, there was still a 
segment of the population who were not tested until they showed 
symptoms of HIV. In addition, according to IHS officials and advocacy 
groups, some American Indians and Alaska Natives did not seek or 
declined testing within IHS due to lack of awareness about the disease, 
confidentiality concerns, and stigma surrounding the disease. For 
example, one UIHP facility staff member said that she usually referred 
individuals to the county health department for HIV testing because the 
facility's clients were afraid that their test results would be 
revealed to IHS staff, many of whom the patients know. An official at 
one organization that provides case management to American Indians and 
Alaska Natives reported that some patients did not seek testing because 
there was a local belief that by being tested one was wishing the 
disease on oneself. 

Other Prevention Services Were Provided: 

In addition to HIV testing and education services, IHS officials 
described some other services that were provided as part of their HIV/ 
AIDS prevention activities. Some IHS officials mentioned that IHS 
facilities were involved in partner notification. For example, an 
official from one area said that public health nurses notified partners 
of patients with HIV and other sexually transmitted diseases, followed 
up with the partners about their testing needs, and provided additional 
counseling. In addition, officials in some areas mentioned that 
facilities in their areas distributed condoms as part of their HIV/AIDS 
prevention activities. For example, a provider in one area made condoms 
available in every exam room at the IHS facilities in the area so that 
patients were no longer ashamed or embarrassed about seeing, taking, or 
asking about condoms. Finally, officials in two areas mentioned that 
tribes in their area had a needle exchange program. 

Some IHS Facilities Provided HIV/AIDS Treatment Services, but Most 
American Indians and Alaska Natives Received Services from Outside 
Providers for a Variety of Reasons: 

While some IHS facilities offered HIV/AIDS treatment services, area 
officials reported that most patients received treatment from providers 
at facilities outside of IHS. Five IHS-funded hospitals regularly 
treated patients and had staff dedicated to providing HIV/AIDS 
treatment. While other facilities provided limited HIV/AIDS treatment, 
most relied on outside providers, such as Ryan White-funded facilities 
or local hospitals. Area officials reported that some patients with 
HIV/AIDS may not access or continue treatment due to a variety of 
reasons, including lack of transportation. 

Five IHS Facilities Regularly Treated Patients with HIV/AIDS: 

Of the more than 45 IHS-funded hospitals, officials from IHS 
headquarters and facilities identified 5 hospitals that regularly 
treated patients with HIV/AIDS. According to IHS headquarters, 3 
facilities have committed the most resources to sustaining HIV/AIDS 
treatment services: the Alaska Native Medical Center in the Alaska 
area, the Gallup Indian Medical Center in the Navajo area, and the HIV 
Center of Excellence at the Phoenix Indian Medical Center in the 
Phoenix area. For example, the Phoenix Indian Medical Center had staff 
such as a physician experienced in treating HIV/AIDS and an HIV 
clinical pharmacist providing HIV/AIDS treatment services. IHS 
officials reported that treatment services were also regularly provided 
at 2 other IHS facilities: the Albuquerque Indian Hospital in the 
Albuquerque area and the W.W. Hastings Indian Medical Center in the 
Oklahoma City area. These 2 facilities each relied on one physician who 
regularly treated patients with HIV/AIDS. Both physicians reported 
seeing patients with HIV/AIDS for over 15 years and continue to provide 
services to patients. 

Officials from all five of the facilities that regularly treated 
patients with HIV/AIDS said that some patients received HIV/AIDS 
services from outside providers. In some cases, the IHS facilities 
coordinated with outside providers for some HIV/AIDS services. For 
example, patients at the Gallup Indian Medical Center and the 
Albuquerque Indian Hospital received case management services outside 
of IHS. The Gallup Indian Medical Center worked with staff from the 
Navajo AIDS Network, an organization that provides case management 
services--including in the Navajo language--to American Indians and 
Alaska Natives with HIV/AIDS. In addition, the Phoenix Indian Medical 
Center's HIV pharmacist arranged for Medicaid-eligible patients to 
receive their HIV drugs by mail through a pharmacy outside of IHS. 

Other IHS Facilities Provided Limited HIV/AIDS Treatment, but Most 
Referred Patients to Outside Providers: 

Several area officials reported that some of the other IHS facilities 
provided limited HIV/AIDS treatment services, but most facilities 
referred patients to outside providers. For example, some facilities 
had physicians with experience treating HIV/AIDS or provided case 
management services to patients with HIV/AIDS. According to officials 
from five areas--Aberdeen, Alaska, Bemidji, Nashville, and Oklahoma 
City--the facilities that provided HIV/AIDS treatment services were 
generally larger IHS-funded facilities, particularly hospitals. For 
example, IHS reported that at least 13 physicians with experience 
treating HIV/AIDS worked at IHS hospitals other than the five 
facilities that regularly provided care. At some facilities that did 
not regularly offer HIV/AIDS treatment services, staff made efforts to 
provide care when needed. For example, officials in two areas-- 
Albuquerque and Bemidji--reported that staff at a facility in their 
area had used a hotline to obtain HIV/AIDS treatment information. In 
addition, one UIHP facility in the California area, which has no IHS- 
funded hospitals, contracted with an HIV/AIDS specialist outside of IHS 
to provide treatment services at the facility once a week. However, 
officials reported that none of the other facilities in the area 
provided HIV/AIDS treatment services. 

Officials from all 12 areas reported that some patients with HIV/AIDS 
were treated outside of IHS, citing a variety of settings. Officials in 
8 areas--Aberdeen, Alaska, Albuquerque, Billings, Nashville, Oklahoma 
City, Phoenix, and Tucson--reported that patients in their areas 
received care from Ryan White-funded facilities. According to HRSA, in 
2005 more than 950 of the 2,463 Ryan White-funded facilities across the 
United States provided services to one or more American Indians or 
Alaska Natives with HIV/AIDS. In addition, IHS officials noted that 
American Indians and Alaska Natives may receive HIV/AIDS treatment 
services from local hospitals or from physicians in private practice. 
Some patients who receive HIV/AIDS treatment outside of IHS may 
continue to receive other types of health care from IHS-funded 
facilities. For example, one IHS official reported that these patients 
might see a specialist quarterly or once a year for their HIV/AIDS 
treatment services and an IHS provider for routine care. An official 
for another area reported that of those patients referred to other 
providers for HIV/AIDS services, most stay with their IHS-funded 
facility for their other health care services. 

IHS area officials noted several reasons why IHS-funded facilities in 
their areas did not provide HIV/AIDS treatment services. 

Too few patients and limited experience. Officials for six areas-- 
Albuquerque, Bemidji, California, Nashville, Oklahoma City, and 
Portland--reported that some facilities did not provide treatment 
because they did not have any patients known to have the disease. 
Officials for eight areas--Aberdeen, Albuquerque, Bemidji, Billings, 
Oklahoma City, Phoenix, Portland, and Tucson--reported that providers' 
lack of training or experience related to HIV/AIDS were reasons why 
HIV/AIDS treatment was not provided at some facilities. Chief medical 
officers from four of the eight areas cited frequently changing HIV/ 
AIDS treatment protocols as a reason why providers might not feel 
comfortable treating the disease. 

Allocation of limited resources. Officials for 10 areas--Aberdeen, 
Albuquerque, Bemidji, Billings, California, Nashville, Oklahoma City, 
Phoenix, Portland, and Tucson--cited limited IHS resources, such as 
funding or staff, as a reason for referring patients outside IHS. 
Officials for 4 of the 10 areas said that, given IHS's limited 
resources, including limited staff, and the availability of HIV/AIDS 
services outside of IHS, they preferred to refer patients to outside 
providers rather than provide HIV/AIDS treatment services in-house. In 
addition, officials in 4 of the 10 areas reported that their pharmacies 
do not provide HAART because of the high cost of the HIV/AIDS drugs or 
because too few patients seek those drugs from IHS. 

Other health concerns. Officials in six areas--Alaska, Bemidji, 
Billings, Oklahoma City, Portland, and Tucson--mentioned that their 
areas have other health concerns that take precedence over HIV/AIDS. 
Among the other more prevalent health concerns mentioned were 
unintentional injuries and diabetes. Moreover, while area officials 
listed diabetes, accidents, and heart disease as some of the 10 leading 
causes of death in their area, only the California area officials 
listed HIV/AIDS as one of the 10 leading causes of death in their area. 
See appendix I for the reasons why IHS-funded facilities did not 
provide HIV/AIDS treatment services, by area. 

Some American Indians and Alaska Natives with HIV/AIDS May Not Access 
or Continue Treatment: 

IHS area officials and facility providers noted that some American 
Indians and Alaska Natives with HIV/AIDS may not access or continue 
care, even if treatment is available, for reasons such as concerns 
about confidentiality and lack of transportation. Officials in the 12 
IHS areas reported that patients' concerns with confidentiality and 
stigma in close-knit communities were reasons why some patients did not 
access care from IHS. Officials from 7 areas--Aberdeen, Alaska, 
Bemidji, California, Navajo, Oklahoma City, and Portland--reported that 
some patients with HIV/AIDS were concerned that their friends or 
relatives who work or access services at IHS would learn about their 
HIV status. For example, an official for one rural area said that in 
villages many people are related to IHS community health aides and 
other service providers, which increases patients' reluctance to 
disclose their HIV status and seek HIV/AIDS treatment services. 
Officials in 7 areas--Alaska, Albuquerque, Bemidji, Billings, Oklahoma 
City, Phoenix, and Tucson--mentioned that distance to HIV/AIDS 
treatment services or lack of transportation may affect American 
Indians' and Alaska Natives' ability to access care. Officials in one 
area reported knowing of an isolated region in one state in the area 
that had "clear unmet needs" because it was located 300 miles from any 
facilities--IHS or otherwise--with HIV/AIDS treatment services. In one 
urban area, an official reported that relying on public transportation 
was a barrier to treatment because it can be unreliable and 
unaffordable for many clients. Area officials in Albuquerque, Phoenix, 
and Navajo said that patients may not access treatment because of 
cultural reasons. One official noted that traditional healing practices 
may take priority over western medicine. In addition, this official 
noted that, in some communities, family obligations may also take 
priority over treatment. For example, he said that a patient may miss 
an appointment because he or she chose to be with a sick family member 
in another state. 

Some area officials reported that there were other factors that could 
affect a patient's continuation of HIV/AIDS treatment, such as alcohol 
or drug abuse or lack of housing. Officials for five areas--Alaska, 
Albuquerque, Navajo, Phoenix, and Tucson--cited concerns with patients 
with HIV/AIDS adhering to their treatment programs, partly due to 
substance abuse. In addition, officials for two IHS-funded facilities 
noted that housing can be of concern. For example, one of the facility 
officials said that an HIV-positive patient from a small community 
moved to a nearby city because the patient's home lacked both heat and 
water, compromising the patient's health. See appendix I for the 
reasons why American Indians and Alaska Natives with HIV/AIDS did not 
access or continue HIV/AIDS treatment services, by area. 

IHS Has HIV/AIDS Outreach and Planning, Capacity Building, and 
Surveillance Initiatives: 

IHS has undertaken outreach and planning, capacity building, and 
surveillance initiatives related to HIV/AIDS. These initiatives are 
overseen by national and area-level officials. IHS's outreach and 
planning initiatives include an HIV/AIDS program Web site, an HIV 
listserv, and a national HIV/AIDS administrative work plan. IHS has 
also carried out several initiatives aimed at building the capacity of 
its providers to offer HIV/AIDS-related prevention and treatment 
services, such as training of health care providers and implementation 
of an HIV-related data system. Additionally, IHS has undertaken 
initiatives related to improving the surveillance of HIV/AIDS in the 
American Indian and Alaska Native population by developing a prenatal 
HIV screening measure and an early detection surveillance system. 

IHS HIV/AIDS Initiatives Oversight: 

IHS initiatives related to HIV/AIDS are overseen by a national IHS HIV/ 
AIDS program official or by officials at the area level. The national 
program is coordinated by an HIV/AIDS principal consultant, the only 
full-time staff member dedicated to these initiatives. Program 
initiatives are often conducted in collaboration with other IHS 
personnel and are supported by IHS[Footnote 29] and outside funding 
sources, such as the Minority AIDS Initiative.[Footnote 30] These 
additional IHS personnel who support IHS's HIV/AIDS initiatives do so 
in addition to other full-time duties. At the area level, HIV/AIDS 
initiatives are often conducted as part of broader health promotion and 
disease prevention programs. Officials in five areas reported having 
staff who acted as area HIV/AIDS coordinators, but few of those staff 
worked full-time on HIV/AIDS and all had other duties, such as 
providing behavioral health education or acting as a consultant for 
other diseases. 

Outreach and Planning Initiatives: 

IHS has undertaken several outreach and planning initiatives, including 
an HIV/AIDS program Web site, an HIV listserv, and a national HIV/AIDS 
administrative work plan. 

Web site. A public Web site, [hyperlink, 
http://www.ihs.gov/MedicalPrograms/HIVAIDS], contains information on 
American Indian and Alaska Native-related HIV/ AIDS research, HIV/AIDS 
clinical treatment guidelines, and links to other relevant Web sites, 
including grant and funding resources. It was launched March 21, 2007, 
on the first National Native HIV/AIDS Awareness Day. As of July 2007, 
the Web site had more than 3,500 unique visitors, an average of 36 
visits a day, according to an IHS official. 

Listserv. The HIV/AIDS principal consultant operates an HIV listserv, 
which e-mails information of general interest to those working with 
American Indians and Alaska Natives with HIV/AIDS, such as HIV/AIDS- 
related news, recent research, and funding opportunities. An IHS 
official reported that the listserv included about 650 individuals, 
including American Indian and Alaska Native community members and 
officials from IHS, tribes, and American Indian and Alaska Native 
advocacy groups. 

HIV/AIDS administrative work plan. According to IHS, as of September 
2007, a national IHS HIV/AIDS administrative work plan was nearing 
completion. The plan is intended to integrate multiple activities to 
help improve IHS surveillance, information sharing, and data 
collection. The plan will determine HIV/AIDS intervention priority 
areas, describe the activities to be conducted within each priority 
area, and identify key personnel and organizations with responsibility 
for each activity. The plan is also intended to be a 3-year 
administrative blueprint for further development and progression of the 
HIV/AIDS program. As of September 2007, the plan was in draft form and 
being circulated both within and outside of IHS for comment. The HIV/ 
AIDS principal consultant said that the work plan would be finalized 
and issued in the fall of 2007. 

Collaboration with other organizations. IHS had signed or was 
developing memoranda of understanding with other organizations, 
including HRSA and the Substance Abuse and Mental Health Services 
Administration (SAMHSA), on various HIV/AIDS activities.[Footnote 31] 
IHS and HRSA have signed a 3-year memorandum of understanding to 
collaborate on multiple HIV/AIDS initiatives in an effort to decrease 
duplication of services, increase awareness of common resources, and 
improve coordination and quality of services to American Indians and 
Alaska Natives. IHS and SAMHSA were developing a memorandum of 
understanding to train IHS staff to conduct HIV/AIDS rapid testing. The 
memorandum was expected to be implemented in early 2008. In addition, 
six areas reported working with local organizations on HIV/AIDS 
initiatives. For example, an official in the Aberdeen area reported 
that the area has an HIV/AIDS task force consisting of clinical 
providers, community health representatives, and HIV coordinators from 
state health departments in the Aberdeen area. The taskforce is 
initiating an HIV strategic plan for the area. 

Capacity Building Initiatives: 

IHS also has carried out several initiatives aimed at building the 
capacity of providers to offer HIV/AIDS-related prevention and 
treatment services. 

HIV/AIDS collaborative training. IHS provides HIV/AIDS training for IHS-
funded staff in 2-and-1/2-day sessions funded by HHS's Minority AIDS 
Initiative. Since fiscal year 2005, the sessions have focused on 
HIV/AIDS behavioral health issues, capacity and partnership building, 
and related intervention strategies. Topics for training to be 
conducted during 2007 and 2008 include: reporting, data collection, 
best practice models, clinical practice issues, prevention policies and 
procedures, and culturally appropriate pre-and posttest counseling 
interview techniques. IHS also plans to use this funding to conduct a 1-
day Traditional Healers Summit to discuss HIV/AIDS with traditional 
healers. IHS officials noted this would be the first training of this 
kind for any disease. 

Training IHS community health representatives. IHS also received 
funding from the Minority AIDS Initiative to provide community health 
representatives with HIV/AIDS-related training.[Footnote 32] These 
training sessions will be presented by health care professionals and 
will teach community health representatives about facts, fears, and 
public perceptions about sexually transmitted diseases, including HIV/ 
AIDS. Community health representatives will also be coached on how to 
present this information on their reservations. These sessions were 
scheduled to take place in November 2007. 

Area-organized training and conferences. In addition to training 
overseen by the IHS HIV/AIDS Program, officials from eight area offices 
reported offering HIV/AIDS regional training sessions or conferences to 
tribal leaders, clinical providers, and community members. For example, 
the Aberdeen area holds an annual conference on HIV/AIDS where 
attendees learn about local resources, funding resources, and possible 
partnership opportunities with IHS, the state, and tribes. 

HIV/AIDS telemedicine support network. With Minority AIDS Initiative 
funding, the HIV Center of Excellence in the Phoenix Indian Medical 
Center created an HIV/AIDS telemedicine support network for health care 
providers in IHS-operated, tribally operated, and UIHP facilities to 
expand the quality and availability of HIV/AIDS communication, 
training, support, and expert consultation. An IHS official said that 
the goal of this network is to increase the availability of HIV/AIDS 
treatment by providing facilities with access to HIV/AIDS experts and 
consultants. The network is still in the developmental stages and, 
according to IHS, is initially being targeted to 16 IHS-funded 
facilities. 

HIV Management System. In September 2006, IHS implemented its HIV 
Management System (HMS), a data system intended to help clinical 
providers and case managers provide quality care to HIV/AIDS patients 
and those at risk for the disease. When a facility enters its data into 
HMS, the system can generate quality-of-care audit reports or send 
reminders to providers when patients with HIV/AIDS need care. IHS 
officials could not estimate how many facilities will use HMS, noting 
that participation is voluntary. As of October 2007, staff from 12 
facilities had been trained in how to use the system. HMS originally 
was funded by the Minority AIDS Initiative; however, IHS did not 
receive funding for fiscal year 2007 to continue this system. IHS 
officials said that despite the loss of funding they will continue to 
support HMS with IHS resources, but that some of their efforts, such as 
the evaluation of the program, will have to be curtailed. Officials 
said they plan to reapply for funding for fiscal year 2008. 

Increased HIV testing. IHS also received funding in fiscal year 2007 
from the Minority AIDS Initiative to continue to increase HIV screening 
at UIHP facilities. Seven awards of approximately $45,000 will be 
issued to urban facilities in order to enhance HIV testing, including 
rapid testing and standard lab-based testing, and to provide a more 
targeted effort to address HIV/AIDS prevention in some of the largest 
urban American Indian and Alaska Native populations in the United 
States. This initiative is expected to expand services to patients, 
build IHS's testing capacity, and collect data about barriers to 
testing services. 

Surveillance Initiatives: 

IHS has undertaken two initiatives to improve surveillance of HIV/AIDS 
in the American Indian and Alaska Native population. 

Prenatal HIV screening. In 2005, IHS implemented a new Government 
Performance and Results Act measure[Footnote 33] that examines the 
percentage of pregnant IHS patients screened for HIV in a 
year.[Footnote 34] The 2006 target for this measure was 55 percent of 
IHS's pregnant patients screened for HIV within the last year; the 
actual percentage of patients screened was 65 percent. For 2007, IHS's 
target was to ensure that the proportion of pregnant female patients 
screened for HIV did not decrease more than 1 percent from the 2006 
level. For 2007, the percentages of pregnant women screened by IHS 
ranged from 48 percent to 88 percent among the areas, with an overall 
screening rate of 74 percent. 

Early detection surveillance system. With funding from the Minority 
AIDS Initiative, IHS is developing a national early warning system to 
detect increases in the rate of HIV infection for American Indian and 
Alaska Native populations at high risk. This initiative aims to enhance 
and improve screening for HIV in prenatal populations by examining a 
sample of IHS facilities from which data are collected electronically. 
From this sample, IHS wants to be able to detect any changes in the 
rates of HIV infection among pregnant women. In addition, the 
initiative includes conducting a knowledge, attitude, and practice 
survey of health care professionals on CDC's new, broader HIV screening 
guidelines to identify misunderstandings and obstacles and accelerate 
the adoption of the new guidelines in IHS funded-facilities. An IHS 
official said that the survey was being developed and was expected to 
be completed by December 2007. The early surveillance initiative also 
seeks to analyze the rate of HIV screening among patients who have 
tested positive for a sexually transmitted disease, patients who have 
tested positive for other diseases that typically coexist with HIV/ 
AIDS, and unique individuals screened for HIV in order to estimate the 
proportion of the IHS user population who are aware of their HIV 
status. 

Agency Comments and Our Evaluation: 

We provided a draft of this report to HHS for comments from IHS, CDC, 
and HRSA. We received written comments from HHS. HHS substantially 
agreed with the findings of our report and offered technical comments 
to provide additional information or clarify specific findings, which 
we incorporated as appropriate. The letter included with HHS's comments 
is reprinted in appendix II. 

Generally, HHS's technical comments requested that we provide 
additional context about IHS's capacity to provide HIV/AIDS prevention 
and treatment services. HHS commented that IHS is mainly a primary care 
system and generally relies on providers outside of IHS for HIV/AIDS 
treatment services. HHS stated that IHS generally refers patients with 
HIV/AIDS to outside providers as they do for other complex conditions, 
such as cancer and heart disease. In addition, HHS noted that the 
barriers to HIV/AIDS testing and misconceptions about the disease 
mentioned in this report are not unique to the American Indian and 
Alaska Native communities. 

We are sending copies of this report to the Secretary of Health and 
Human Services. We will also make copies available to others on 
request. In addition, the report will be available at no charge on 
GAO's Web site at [hyperlink, http://www.gao.gov]. 

If you or your staff have questions about this report, please contact 
me at (202) 512-7114 or ekstrandl@gao.gov. Contact points for our 
Office of Congressional Relations and Public Affairs may be found on 
the last page of this report. GAO staff who made major contributions to 
this report are listed in appendix III. 

Signed by: 

Laurie Ekstrand: 

Director, Health Care: 

[End of section] 

Appendix I Reasons Why Treatment Services May Not Be Offered or 
Accessed, as Reported by IHS Area Officials: 

Table 3: 

IHS area: Aberdeen; 
Reasons why some IHS-funded facilities did not offer services: No known 
patients with HIV/AIDS: [Empty]; 
Reasons why some IHS-funded facilities did not offer services: Limited 
resources: Check; 
Reasons why some IHS-funded facilities did not offer services: Other 
health concerns: [Empty]; 
[Empty]; 
Reasons why American Indians and Alaska Natives with HIV/AIDS may not 
access or continue treatment: Confidentiality concerns: Check; 
Reasons why American Indians and Alaska Natives with HIV/AIDS may not 
access or continue treatment: Distance or lack of transportation: 
[Empty]; 
Reasons why American Indians and Alaska Natives with HIV/AIDS may not 
access or continue treatment: Cultural reasons: [Empty]; 
Reasons why American Indians and Alaska Natives with HIV/AIDS may not 
access or continue treatment: Alcohol or drug abuse: [Empty]; 
Reasons why American Indians and Alaska Natives with HIV/AIDS may not 
access or continue treatment: Lack of housing: [Empty]. 

IHS area: Alaska; 
Reasons why some IHS-funded facilities did not offer services: No known 
patients with HIV/AIDS: [Empty]; 
Reasons why some IHS-funded facilities did not offer services: Limited 
resources: [Empty]; 
Reasons why some IHS-funded facilities did not offer services: Other 
health concerns: Check; 
[Empty]; 
Reasons why American Indians and Alaska Natives with HIV/AIDS may not 
access or continue treatment: Confidentiality concerns: Check; 
Reasons why American Indians and Alaska Natives with HIV/AIDS may not 
access or continue treatment: Distance or lack of transportation: 
Check; 
Reasons why American Indians and Alaska Natives with HIV/AIDS may not 
access or continue treatment: Cultural reasons: [Empty]; 
Reasons why American Indians and Alaska Natives with HIV/AIDS may not 
access or continue treatment: Alcohol or drug abuse: Check; 
Reasons why American Indians and Alaska Natives with HIV/AIDS may not 
access or continue treatment: Lack of housing: [Empty]. 

IHS area: Albuquerque; 
Reasons why some IHS-funded facilities did not offer services: No known 
patients with HIV/AIDS: Check; 
Reasons why some IHS-funded facilities did not offer services: Limited 
resources: Check; 
Reasons why some IHS-funded facilities did not offer services: Other 
health concerns: [Empty]; 
[Empty]; 
Reasons why American Indians and Alaska Natives with HIV/AIDS may not 
access or continue treatment: Confidentiality concerns: Check; 
Reasons why American Indians and Alaska Natives with HIV/AIDS may not 
access or continue treatment: Distance or lack of transportation: 
Check; 
Reasons why American Indians and Alaska Natives with HIV/AIDS may not 
access or continue treatment: Cultural reasons: Check; 
Reasons why American Indians and Alaska Natives with HIV/ AIDS may not 
access or continue treatment: Alcohol or drug abuse: Check; 
Reasons why American Indians and Alaska Natives with HIV/AIDS may not 
access or continue treatment: Lack of housing: [Empty]. 

IHS area: Bemidji; 
Reasons why some IHS-funded facilities did not offer services: No known 
patients with HIV/AIDS: Check; 
Reasons why some IHS- funded facilities did not offer services: Limited 
resources: Check; 
Reasons why some IHS-funded facilities did not offer services: Other 
health concerns: Check; 
[Empty]; 
Reasons why American Indians and Alaska Natives with HIV/AIDS may not 
access or continue treatment: Confidentiality concerns: Check; 
Reasons why American Indians and Alaska Natives with HIV/ AIDS may not 
access or continue treatment: Distance or lack of transportation: 
Check; 
Reasons why American Indians and Alaska Natives with HIV/AIDS may not 
access or continue treatment: Cultural reasons: [Empty]; 
Reasons why American Indians and Alaska Natives with HIV/AIDS may not 
access or continue treatment: Alcohol or drug abuse: [Empty]; 
Reasons why American Indians and Alaska Natives with HIV/AIDS may not 
access or continue treatment: Lack of housing: [Empty]. 

IHS area: Billings; 
Reasons why some IHS-funded facilities did not offer services: No known 
patients with HIV/AIDS: [Empty]; 
Reasons why some IHS-funded facilities did not offer services: Limited 
resources: Check; 
Reasons why some IHS-funded facilities did not offer services: Other 
health concerns: Check; 
[Empty]; 
Reasons why American Indians and Alaska Natives with HIV/AIDS may not 
access or continue treatment: Confidentiality concerns: Check; 
Reasons why American Indians and Alaska Natives with HIV/AIDS may not 
access or continue treatment: Distance or lack of transportation: 
Check; 
Reasons why American Indians and Alaska Natives with HIV/AIDS may not 
access or continue treatment: Cultural reasons: [Empty]; 
Reasons why American Indians and Alaska Natives with HIV/AIDS may not 
access or continue treatment: Alcohol or drug abuse: [Empty]; 
Reasons why American Indians and Alaska Natives with HIV/AIDS may not 
access or continue treatment: Lack of housing: [Empty]. 

IHS area: California; 
Reasons why some IHS-funded facilities did not offer services: No known 
patients with HIV/AIDS: Check; 
Reasons why some IHS-funded facilities did not offer services: Limited 
resources: Check; 
Reasons why some IHS-funded facilities did not offer services: Other 
health concerns: [Empty]; 
[Empty]; 
Reasons why American Indians and Alaska Natives with HIV/AIDS may not 
access or continue treatment: Confidentiality concerns: Check; 
Reasons why American Indians and Alaska Natives with HIV/AIDS may not 
access or continue treatment: Distance or lack of transportation: 
[Empty]; 
Reasons why American Indians and Alaska Natives with HIV/AIDS may not 
access or continue treatment: Cultural reasons: [Empty]; 
Reasons why American Indians and Alaska Natives with HIV/AIDS may not 
access or continue treatment: Alcohol or drug abuse: [Empty]; 
Reasons why American Indians and Alaska Natives with HIV/AIDS may not 
access or continue treatment: Lack of housing: [Empty]. 

IHS area: Nashville; 
Reasons why some IHS-funded facilities did not offer services: No known 
patients with HIV/AIDS: Check; 
Reasons why some IHS-funded facilities did not offer services: Limited 
resources: Check; 
Reasons why some IHS-funded facilities did not offer services: Other 
health concerns: [Empty]; 
[Empty]; 
Reasons why American Indians and Alaska Natives with HIV/AIDS may not 
access or continue treatment: Confidentiality concerns: Check; 
Reasons why American Indians and Alaska Natives with HIV/AIDS may not 
access or continue treatment: Distance or lack of transportation: 
[Empty]; 
Reasons why American Indians and Alaska Natives with HIV/AIDS may not 
access or continue treatment: Cultural reasons: [Empty]; 
Reasons why American Indians and Alaska Natives with HIV/AIDS may not 
access or continue treatment: Alcohol or drug abuse: [Empty]; 
Reasons why American Indians and Alaska Natives with HIV/AIDS may not 
access or continue treatment: Lack of housing: [Empty]. 

IHS area: Navajo; 
Reasons why some IHS-funded facilities did not offer services: No known 
patients with HIV/AIDS: [Empty]; 
Reasons why some IHS-funded facilities did not offer services: Limited 
resources: [Empty]; 
Reasons why some IHS-funded facilities did not offer services: Other 
health concerns: [Empty]; 
[Empty]; 
Reasons why American Indians and Alaska Natives with HIV/AIDS may not 
access or continue treatment: Confidentiality concerns: Check; 
Reasons why American Indians and Alaska Natives with HIV/AIDS may not 
access or continue treatment: Distance or lack of transportation: 
[Empty]; 
Reasons why American Indians and Alaska Natives with HIV/AIDS may not 
access or continue treatment: Cultural reasons: Check; 
Reasons why American Indians and Alaska Natives with HIV/AIDS may not 
access or continue treatment: Alcohol or drug abuse: Check; 
Reasons why American Indians and Alaska Natives with HIV/AIDS may not 
access or continue treatment: Lack of housing: [Empty]. 

IHS area: Oklahoma City; 
Reasons why some IHS-funded facilities did not offer services: No known 
patients with HIV/AIDS: Check; 
Reasons why some IHS-funded facilities did not offer services: Limited 
resources: Check; 
Reasons why some IHS-funded facilities did not offer services: Other 
health concerns: Check; 
[Empty]; 
Reasons why American Indians and Alaska Natives with HIV/AIDS may not 
access or continue treatment: Confidentiality concerns: Check; 
Reasons why American Indians and Alaska Natives with HIV/AIDS may not 
access or continue treatment: Distance or lack of transportation: 
Check; 
Reasons why American Indians and Alaska Natives with HIV/AIDS may not 
access or continue treatment: Cultural reasons: [Empty]; 
Reasons why American Indians and Alaska Natives with HIV/AIDS may not 
access or continue treatment: Alcohol or drug abuse: [Empty]; 
Reasons why American Indians and Alaska Natives with HIV/AIDS may not 
access or continue treatment: Lack of housing: [Empty]. 

IHS area: Phoenix; 
Reasons why some IHS-funded facilities did not offer services: No known 
patients with HIV/AIDS: [Empty]; 
Reasons why some IHS-funded facilities did not offer services: Limited 
resources: Check; 
Reasons why some IHS-funded facilities did not offer services: Other 
health concerns: [Empty]; 
[Empty]; 
Reasons why American Indians and Alaska Natives with HIV/AIDS may not 
access or continue treatment: Confidentiality concerns: Check; 
Reasons why American Indians and Alaska Natives with HIV/AIDS may not 
access or continue treatment: Distance or lack of transportation: 
Check; 
Reasons why American Indians and Alaska Natives with HIV/AIDS may not 
access or continue treatment: Cultural reasons: Check; 
Reasons why American Indians and Alaska Natives with HIV/ AIDS may not 
access or continue treatment: Alcohol or drug abuse: Check; 
Reasons why American Indians and Alaska Natives with HIV/AIDS may not 
access or continue treatment: Lack of housing: Check. 

IHS area: Portland; 
Reasons why some IHS-funded facilities did not offer services: No known 
patients with HIV/AIDS: Check; 
Reasons why some IHS-funded facilities did not offer services: Limited 
resources: Check; 
Reasons why some IHS-funded facilities did not offer services: Other 
health concerns: Check; 
[Empty]; 
Reasons why American Indians and Alaska Natives with HIV/AIDS may not 
access or continue treatment: Confidentiality concerns: Check; 
Reasons why American Indians and Alaska Natives with HIV/AIDS may not 
access or continue treatment: Distance or lack of transportation: 
[Empty]; 
Reasons why American Indians and Alaska Natives with HIV/AIDS may not 
access or continue treatment: Cultural reasons: [Empty]; 
Reasons why American Indians and Alaska Natives with HIV/AIDS may not 
access or continue treatment: Alcohol or drug abuse: [Empty]; 
Reasons why American Indians and Alaska Natives with HIV/AIDS may not 
access or continue treatment: Lack of housing: [Empty]. 

IHS area: Tucson; 
Reasons why some IHS-funded facilities did not offer services: No known 
patients with HIV/AIDS: [Empty]; 
Reasons why some IHS-funded facilities did not offer services: Limited 
resources: Check; 
Reasons why some IHS-funded facilities did not offer services: Other 
health concerns: Check; 
[Empty]; 
Reasons why American Indians and Alaska Natives with HIV/AIDS may not 
access or continue treatment: Confidentiality concerns: Check; 
Reasons why American Indians and Alaska Natives with HIV/AIDS may not 
access or continue treatment: Distance or lack of transportation: 
Check; 
Reasons why American Indians and Alaska Natives with HIV/AIDS may not 
access or continue treatment: Cultural reasons: [Empty]; 
Reasons why American Indians and Alaska Natives with HIV/AIDS may not 
access or continue treatment: Alcohol or drug abuse: Check; 
Reasons why American Indians and Alaska Natives with HIV/AIDS may not 
access or continue treatment: Lack of housing: Check. 

Total; 
Reasons why some IHS-funded facilities did not offer services: No known 
patients with HIV/AIDS: 6; 
Reasons why some IHS- funded facilities did not offer services: Limited 
resources: 10; 
Reasons why some IHS-funded facilities did not offer services: Other 
health concerns: 6; 
[Empty]; 
Reasons why American Indians and Alaska Natives with HIV/AIDS may not 
access or continue treatment: Confidentiality concerns: 12; 
Reasons why American Indians and Alaska Natives with HIV/AIDS may not 
access or continue treatment: Distance or lack of transportation: 7; 
Reasons why American Indians and Alaska Natives with HIV/AIDS may not 
access or continue treatment: Cultural reasons: 3; 
Reasons why American Indians and Alaska Natives with HIV/ AIDS may not 
access or continue treatment: Alcohol or drug abuse: 5; 
Reasons why American Indians and Alaska Natives with HIV/AIDS may not 
access or continue treatment: Lack of housing: 2. 

Source: GAO analysis of interviews with IHS officials in the 12 area 
offices. 

Note: The reasons why HIV/AIDS treatment services were not offered, 
accessed, or continued were provided by IHS officials during our 
interviews with the 12 area offices and may not constitute an all- 
inclusive list. 

[End of table] 

[End of section] 

Appendix II: Comments from the Indian Health Service: 

Department Of Health & Human Services: 
Office of the Assistant Secretary for Legislation: 
Washington, D.C. 20201: 

November 14, 2007: 

Laurie E. Ekstrand: 
Director, Health Care U.S. Government Accountability Office: 
Washington, DC 20548: 

Dear Ms. Ekstrand: 

Enclosed are the Department's comments on the U.S. Government 
Accountability Office's (GAO) draft report entitled, "Indian Health 
Service: HIV/AIDS Prevention and Treatment Services for American 
Indians and Alaska Natives" (GAO-08-90). 

The Department substantially agrees with the findings and conclusions 
of the report. The Indian Health Service would like to offer the 
following comments and suggestions listed on Attachment A that will 
help clarify certain issues and provide additional information on 
specific findings. 

The Department has provided several technical comments directly to your 
staff. 

The Department appreciates the opportunity to review and comment on 
this draft before its publication. 

Sincerely,

Rebecca Hemard for: 

Vincent J. Ventimiglia: 

Assistant Secretary for Legislation: 

[End of section] 

Appendix III: GAO Contact and Staff Acknowledgments: 

GAO Contact: 

Laurie Ekstrand at (202) 512-7114 or ekstrandl@gao.gov: 

Acknowledgments: 

In addition to the contact named above, Karen Doran, Assistant 
Director; Catina Bradley; Adrienne Griffin; Christina Ritchie; Eden 
Savino; and Timothy Walker made key contributions to this report. 

[End of section] 

Related GAO Products: 

Ryan White CARE Act: Changes Needed to Improve the Distribution of 
Funding. GAO-06-703T. Washington, D.C.: April 27, 2006. 

Ryan White CARE Act: AIDS Drug Assistance Programs, Perinatal HIV 
Transmission, and Partner Notification. GAO-06-681T. Washington, D.C.: 
April 26, 2006. 

Ryan White CARE Act: Improved Oversight Needed to Ensure AIDS Drug 
Assistance Programs Obtain Best Prices for Drugs. GAO-06-646. 
Washington, D.C.: April 26, 2006. 

HIV/AIDS: Changes Needed to Improve the Distribution of Ryan White CARE 
Act and Housing Funds. GAO-06-332. Washington, D.C.: February 28, 2006. 

Indian Health Service: Health Care Services Are Not Always Available to 
Native Americans. GAO-05-789. Washington, D.C.: August 31, 2005. 

Ryan White CARE Act: Factors that Impact HIV and AIDS Funding and 
Client Coverage. GAO-05-841T. Washington, D.C.: June 23, 2005. 

[End of section] 

Footnotes: 

[1] In 2005, the rate (per 100,000 persons) of HIV/AIDS diagnosis for 
American Indians and Alaska Natives was 10.4, compared with 71.3 for 
blacks, 27.8 for Hispanics, 8.8 for whites, and 7.4 for Asians and 
Pacific Islanders. See Department of Health and Human Services, Centers 
for Disease Control and Prevention, HIV/AIDS among American Indians and 
Alaska Natives (Atlanta, Ga: 2007). 

[2] CDC has AIDS surveillance data available for all 50 states. 
However, CDC's estimates for persons living with HIV/AIDS include only 
those 33 states and U.S. dependent areas that have had confidential 
name-based HIV infection reporting since 2001, and not all states with 
large American Indian and Alaska Native populations have been 
conducting HIV surveillance. As a result, we cannot provide a more 
precise estimate of the total number of American Indians and Alaska 
Natives living with HIV. Therefore, in this report, we use CDC's 
reported AIDS data only. 

[3] In addition, the numbers of HIV and AIDS diagnoses for American 
Indians and Alaska Natives may be affected by racial misclassification. 
This occurs when patients either self-identify or are identified by 
health care providers as being of a racial or ethnic group other than 
American Indian and Alaska Native. 

[4] American Indians and Alaska Natives eligible for IHS services must 
generally be members of federally recognized tribes or their 
descendants. In addition, they must be regarded as American Indians and 
Alaska Natives by their community, as evidenced by such factors as 
living on tax-exempt land, owning restricted property, participating 
actively in tribal affairs, or other relevant factors. Non-American 
Indians and Alaska Natives may in certain very limited circumstances 
also be eligible for services. 

[5] The UIHP consists of 34 nonprofit organizations nationwide that are 
funded through grants and contracts from IHS. 

[6] GAO, Indian Health Service: Health Care Services Are Not Always 
Available to Native Americans, GAO-05-789 (Washington, D.C.: August 
2005). 

[7] Medicare is a federal health insurance program for individuals aged 
65 and older and for certain disabled adults. Medicaid is a jointly 
funded federal-state health care program that covers certain low-income 
individuals and families, including those who are aged or disabled. The 
Ryan White CARE Act of 1990, referred to in this report as the Ryan 
White program, makes funds available to states, territories, and 
metropolitan areas to provide health care and support services to 
individuals and families affected by HIV/AIDS. 

[8] In general, tribes that receive funds from IHS to operate health 
facilities are required only to submit to the single-agency audit 
requirements of 31 U.S.C.  7501-07. See 25 U.S.C.  450c; 25 C.F.R.  
900.3(a)(6); 42 C.F.R.  137.165. In addition, IHS may negotiate with 
the tribes to require additional reporting as part of any funding 
agreement. Finally, certain funding arrangements require tribes to 
submit an annual report on health status and service delivery; however, 
these reports are not intended to be a quality assessment or monitoring 
tool and the contents of the reports are negotiated by IHS and the 
tribes. See 42 C.F.R.  137.200-137.207. 

[9] IHS defines its user population as the number of American Indians 
and Alaska Natives, residing within an IHS service delivery area, with 
at least one visit during the prior 3 fiscal years. 

[10] According to the 2000 U.S. Census, American Indians and Alaska 
Natives represented 1.5 percent of the U.S. population--about 4.1 
million individuals. Of the 4.1 million, about 2.5 million self- 
identified as solely American Indian or Alaska Native and about 1.6 
million self-identified as both American Indian or Alaska Native and 
part of one or more other racial group. 

[11] Under the federal laws governing health services for Indians, 
tribes have three options for receiving their health care: (1) directly 
from IHS; (2) through contracting with IHS to have the administrative 
control, operation, and funding for health programs transferred to 
American Indian and Alaska Native tribal governments; or (3) through 
compacting with IHS and assuming even greater control and autonomy for 
the provision of their own health care services. See 25 U.S.C.  1601- 
1683; 25 U.S.C.  450 et seq. 

[12] In addition, the appropriation included $353 million for IHS for 
the construction, repair, maintenance, improvement, and equipment of 
health and related facilities. 

[13] Tribally operated facilities are also permitted to bill Medicare, 
Medicaid, and private insurance for reimbursement for services 
provided. These facilities are generally allowed to retain 
reimbursements, without an offsetting reduction in their IHS funding, 
in order to fund health services. See 25 U.S.C.  1621f, 1645. 

[14] According to IHS, the final total amount appropriated for contract 
health services in fiscal year 2006 was about $517 million, which 
includes funds appropriated for contract medical care and funds 
appropriated for the Indian Catastrophic Health Emergency Fund. 

[15] To be eligible for contract care, an American Indian or Alaska 
Native generally must already be eligible for IHS direct services, 
reside within a county that is part of one of the 12 IHS areas, and 
either (1) reside on a reservation within the area or on certain 
traditional American Indian or Alaska Native lands, or (2) belong to or 
maintain close economic and social ties with a tribe based on such a 
reservation. Contract care funds may only be used to pay for services 
when patients are unable to obtain such services through other sources, 
including Medicare, Medicaid, or private insurance. 

[16] U.S. Department of Health and Human Services, Centers for Disease 
Control and Prevention, Comprehensive HIV Prevention: Essential 
Components of a Comprehensive Strategy to Prevent Domestic HIV 2006 
(Atlanta, Ga: 2006). 

[17] These guidelines are available on HHS's AIDSInfo Web site, which 
provides information on HIV/AIDS prevention, treatment, and research, 
at [hyperlink, 
http://aidsinfo.nih.gov/Guidelines/Default.aspx?MenuItem=Guidelines] 
(downloaded September 27, 2007). 

[18] Heckman et al., "Barriers to care among persons living with HIV/ 
AIDS in urban and rural areas," AIDS Care 10 (1998): 365-375. 

[19] U.S. Department of Health and Human Services, Centers for Disease 
Control and Prevention, HIV/AIDS Surveillance Report: Cases of HIV 
Infection and AIDS in the United States and Dependent Areas, 2005, 
vol.17 (Atlanta, Ga: 2007). 

[20] Distribution of persons estimated to be living with AIDS by race/ 
ethnicity at the end of 2005, [hyperlink, 
http://www.statehealthfacts.org] (October 3, 2007). CDC provided these 
data to the Kaiser Family Foundation as a special request. 

[21] U.S. Department of Health and Human Services, Centers for Disease 
Control and Prevention, Sexually Transmitted Disease Surveillance 2005 
(Atlanta, Ga: 2006). 

[22] Sexual behaviors that facilitate the spread of HIV include having 
unprotected sex with men who have sex with men, multiple partners, or 
anonymous partners. 

[23] U.S. Department of Health and Human Services, Centers for Disease 
Control and Prevention, HIV/AIDS among American Indians and Alaska 
Natives (Atlanta, Ga: 2007). 

[24] National Center for Health Statistics, Health, United States, 2006 
With Chartbook on Trends in the Health of Americans (Hyattsville, Md: 
2006). 

[25] U.S. Department of Health and Human Services, Centers for Disease 
Control and Prevention, HIV/AIDS among American Indians and Alaska 
Natives (Atlanta, Ga: 2007). 

[26] GAO has published several products on the Ryan White program. See 
Related GAO Products at the end of this report. 

[27] The Community Health Representatives program is an IHS-funded and 
primarily tribally operated program of community-based health care 
workers who provide health promotion and disease prevention services in 
their communities. 

[28] CDC notes that, to be effective, HIV/AIDS prevention interventions 
must be tailored to specific audiences. Each of the 562 federally 
recognized tribes has its own culture, beliefs, practices, and 
sometimes languages, making it challenging to create programs for each 
tribe. 

[29] The IHS headquarters budget includes funds for HIV/AIDS--about 
$425,000 in fiscal year 2006. However, tribes have the option to take 
the HIV/AIDS program funds to directly provide HIV/AIDS services. Any 
funds not taken by the tribes are available for use by the headquarters 
HIV/AIDS program. The amount taken by the tribes varies from year to 
year. In fiscal year 2006, there was about $13,000 left after tribal 
shares were used. 

[30] The Minority AIDS Initiative was created in 1998 in response to 
growing concern about the effect of HIV/AIDS on racial and ethnic 
minorities in the United States. The initiative's principal goals are 
to improve HIV-related health outcomes for racial and ethnic minority 
communities disproportionately affected by HIV/AIDS and reduce HIV- 
related health disparities. It does this by providing new funding 
designed to strengthen organizational capacity and expand HIV-related 
services in minority communities. Administration of the Minority AIDS 
Initiative is decentralized across eight federal agencies and offices, 
primarily within HHS. IHS does not receive an annual budget assignment 
of Minority AIDS Initiative funds; instead, IHS submits annual 
proposals to HHS's Office of HIV/AIDS Policy in Washington, D.C. each 
November. The Minority AIDS Initiative office then grades the proposals 
and notifies the IHS HIV/AIDS principal consultant of the amount of 
funds to be distributed. 

[31] SAMHSA is the lead federal agency responsible for improving the 
quality and availability of prevention and treatment services for 
substance abuse and mental illness. 

[32] Community health representatives provide health promotion and 
disease prevention services in their communities. 

[33] The Government Performance and Results Act of 1993 requires 
federal agencies to demonstrate that they are using their funds 
effectively toward meeting their missions. The law requires agencies to 
have a 5- year strategic plan in place and to submit annual performance 
plans and reports with their budget requests. See 5 U.S.C.  306 (5-
year strategic plan) and 31 U.S.C.  1115 (annual performance plan). 
The annual performance plan must contain specific performance measures 
for that 1-year period. The Government Performance and Results Act year 
runs from July 1 through June 30. 

[34] This measure represents the percentage of pregnant patients 
screened for HIV at IHS-funded facilities. However, because tribes are 
not required to report data, this measure reflects data from only those 
tribally operated facilities that choose to report to IHS. IHS 
estimates that about 85 percent of patients seen in tribally operated 
facilities were included in these measures. 

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