Journal of HIV/AIDS & Social Services, 9:110–129, 2010

Copyright # Taylor & Francis Group, LLC

ISSN: 1538-1501 print=1538-151X online
DOI: 10.1080/15381501003795444

Tribally-Driven HIV/AIDS Health Services

Partnerships: Evidence-Based Meets
Culture-Centered Interventions

BONNIE DURAN, DrPH

School of Public Health, Department of Health Services, University of Washington,
Seattle, Washington, USA

MELVIN HARRISON and MAYNARD SHURLEY

Navaho AIDS Network, Gallup, New Mexico, USA

KEVIN FOLEY, PhD and PRISCILLA MORRIS

Na’Nizhoozhi Center, Inc., Gallup, New Mexico, USA

LYNN DAVIDSON-STROH, MD
Psychiatry Associates-Gallup, Gallup, New Mexico, USA

JONATHAN IRALU, MD
Gallup Indian Medical Center, Gallup, New Mexico, USA

YIZHOU JIANG, MS
University of New Mexico, Albuquerque, New Mexico, USA

MICHELE PEAKE ANDRASIK, PhD

Department of Psychiatry & Behavioral Sciences, University of Washington,
Seattle, Washington, USA

The writing of this article was made possible in part by a grant from the U.S. Department
of Health and Human Services, Health Resources and Services Administration’s (HRSA) Special
Projects of National Significance (SPNS), Grant 5H97HA00254-01-00, and by the Network for
Multicultural Research on Health and Healthcare, Department of Family Medicine–UCLA
David Geffen School of Medicine, funded by the Robert Wood Johnson Foundation. Points
of view in this article are those of the authors and do not necessarily represent the official
views of the HRSA, the University of New Mexico (UNM), the University of Washington, or
the Na’Nizhoozhi Center Inc. (NCI, a substance abuse recovery center located in Gallup,
New Mexico).
The institutional review boards of UNM’s Health Science Center and the Navajo Nation1
approved this study.
Finally, we thank Leo Egashira, who edited this article.
Address correspondence to Bonnie Duran, DrPH, School of Public Health, Department of
Health Services, University of Washington, Box 357660, Seattle, WA 98195-7660, USA. E-mail:
bonduran@u.washington.edu

110
 Tribally-Driven HIV/AIDS Health Services Partnerships 111

This paper describes a successful HIV=AIDS prevention and treat-

ment project that combined medical, support, and educational
services, thereby improving care in a rural American Indian
tribe in the southwestern United States. Using the methods of
community-based participatory evaluation and motivational
interviewing, the 5-year, multiparty collaborative project improved
health care access and medical regimen adherence of people with
HIV=AIDS and increased the risk- and protective-factor knowledge
of tribal members at high risk for the disease. The success of the
collaborative in achieving all these goals highlights the importance
of tribal control, collaboration, and incorporation of tradition and
culture in HIV=AIDS diagnostic, treatment, and prevention efforts.

KEYWORDS alcohol abuse, American Indian, community-based

participatory evaluation, community-led partnerships, drug abuse,
HIV care, HIV screening, HIV=AIDS, mental illness, Native American

INTRODUCTION

While HIV=AIDS has spread throughout every demographic group in the

United States, prevention and treatment strategies still reflect an emphasis
on the first demographic group to have been affected (gay, urban whites)
and a secondary emphasis on the current, most-at-risk group (urban African
Americans). These specific, demographically targeted prevention and
treatment strategies do not address the growing threat of HIV=AIDS among
American Indians (AIs) who live on rural reservations. In addition, federal
and state public health agencies often mandate the use of evidence-based
interventions without providing sufficient resources or time to translate those
efforts to fit the cultural and historical context of local communities.
The Four Corners American Indian Circle of Services Collaborative, a
Navajo Nation–wide collaborative in New Mexico and Arizona, overcame both
of these current limitations by focusing on a lesser-known, high-risk group and
by showing the effectiveness of culturally supported interventions that emerge
from grassroots, local educational and social service programs and in align-
ment with traditional AI values, social norms, and administrative structures
(Duran, Wallerstein, & Miller, 2007; Dutta, 2007). The Four Corners American
Indian Circle of Services Collaborative broke new ground in the development
of integrated HIV=AIDS care on the vast, remote Navajo Nation by becoming
the first AI-led collaboration to test the efficacy of the Navajo AIDS Network
case management intervention for rural, HIV-positive AIs. This was achieved
through the commitment to tribal leadership and multisector engagement in
the conceptualization, development, implementation, and evaluation of a
culturally supported and evidence-based, 5-year comprehensive HIV=AIDS
112 B. Duran et al.

program. Within the context of chronic health service and health status
inequities and rural frontier location, the Four Corners American Indian Circle
of Services Collaborative partners created high-quality, integrated medical=
mental health=cultural systems to serve the needs of people with HIV=AIDS
on the Navajo Nation. In addition to health services, the Four Corners
American Indian Circle of Services Collaborative successfully provided health
promotion=prevention services and increased HIV testing to high-risk groups.
This paper describes the Four Corners American Indian Circle of Services
Collaborative and provides outcome data demonstrating the importance and
success of community-led, culturally supported health services and health
promotion=disease prevention interventions.
The goals of the Four Corners American Indian Circle of Services Colla-
borative project were to (1) increase discovery of HIV status through edu-
cation, screening, and HIV testing services among at-risk AIs who use
alcohol and drugs; (2) increase the number of multiply diagnosed AIs who
are receiving culturally appropriate and consistent health care for their HIV
infections and other sexually transmitted diseases (STDs), substance abuse,
and mental health issues; and (3) reduce new HIV infection on and near
the Navajo Nation by offering appropriate and effective risk reduction sup-
port to multiply diagnosed AIs.

BACKGROUND

The Growing Threat in the Rural Frontier—HIV=AIDS and the

Colonial Health Deficit4
Between 2001 and 2005, HIV=AIDS cases among American Indian=Alaska
Native (AI=AN)3 people in the United States increased at a rate of 10.6
per 100,000 people (Centers for Disease Control and Prevention [CDC],
2008), significantly higher than that of whites. There are multiple social
determinants of HIV infection and barriers to HIV and other STD testing
and treatment, including well-founded fears of stigma and discrimination,
distrust of Western medicine, fear of breach of confidentiality, lack of
HIV=AIDS treatment and medication, and complex social and sexual
networks (Duran et al., 2005). The determinants of infection and barriers
to treatment and prevention stem from both historic and contemporary
conditions and in combination can be thought of as ‘‘the Colonial Health
Deficit.’’ This deficit is the cumulative vulnerability—i.e., epidemic disease,
forced removal, warfare, and white cultural hegemony—that colonization
has had on the physical manifestation of health among indigenous
peoples.4 Furthermore, the current-day legacy of this history is underfund-
ing and the cultural disconnect between the U.S. health care delivery
system and indigenous norms and values (U.S. Commission on Civil
Rights, 2003).
 Tribally-Driven HIV/AIDS Health Services Partnerships 113

Despite these economic, social, and cultural barriers to testing, in 2005,

there were 195 new HIV=AIDS cases identified among AI=AN in the United
States, bringing the total number of AI=AN living with AIDS to 1,595
(CDC, 2008).
The Navajo Nation can be characterized as a culturally intact, but
economically challenged, area. Forty-three percent of the entire population
lives below the poverty level and 68% speak the Navajo language at home
routinely or exclusively, the highest proportion of any tribe in the country
(Ogunwole & U.S. Census Bureau, 2006).
In 2006, the Navajo Area Indian Health Service (NAIHS) reported 22
new HIV=AIDS cases, of whom 10 (44%) had AIDS (Iralu, 2007). Previously,
the majority of people tested for HIV by the NAIHS had already progressed to
AIDS. The increased percentage of new HIV, but pre-AIDS, cases suggests
that the Four Corners American Indian Circle of Services Collaborative has
been successful in increasing access to and acceptance of HIV testing and
treatment. Of the newly reported cases, most (18 of 22) were diagnosed
on the Navajo Nation. Among the new cases diagnosed by NAIHS, the
predominant risk factors for HIV were men who have sex with men
(MSM), followed by heterosexual contact. Increasing rates of HIV infection,
coupled with high rates of alcohol and substance abuse and STDs, pose an
immediate concern to Navajo communities, yet Navajo social and cultural tra-
ditions may offer an important counterbalance to the spread of disease. High
levels of trauma and health and social inequities are considered to be primary
causes of Navajo social problems (Jones, 2006). Access to Western health
care is often stymied by lack of transportation, distance to health care facili-
ties, poverty, and a shortage of mental health and substance abuse services
(Duran et al., 2005). Most Navajos have no private health insurance and
rely on the overburdened NAIHS, currently funded at 50% of the level
needed for primary and secondary care (U.S. Commission on Civil Rights,
2003).
There are many Navajo spiritual, cultural, and social assets and strengths
that mitigate these health problems. Access to traditional Navajo medicine is
widespread and highly used (Novins, Beals, Moore, Spicer, & Manson, 2004).
Extensive use of the Navajo language and the nearly universal practice of cul-
tural traditions and ceremonies build connection to community, culture,
group, clan, and extended family. Nuclear and extended family networks
are strong and provide social, material, and emotional support. The colla-
borative approach that characterizes this intervention is an adaptation of
the Navajo cultural principle of K’e (the clanship system), harnessed for
the purpose of integrating mainstream and traditional systems of care. Tra-
ditional teachings prescribe wellness, balance, and harmony and provide a
mental framework for HIV=AIDS patient wellness (Zolbrod, 1984).
Although AI HIV-specific literature is extremely limited, and has been
characterized as ‘‘obscure and elusive’’ (Kaufman et al., 2007), investigators
114 B. Duran et al.

have found that use of highly active antiretroviral therapy (HAART) among
AI=AN individuals living with HIV led to improvements in CD4 counts and
was the strongest predictor of improved survival (Gorgos, Avery, Bletzer,
& Wilson, 2006). Further, earlier diagnosis and access to effective medical
treatment reduce the burden of HIV infection in AI=AN communities (Gorgos
et al., 2006).
As outlined later, the success of the Four Corners American Indian
Circle of Services Collaborative validates the importance of target popula-
tions taking the lead in developing multisector collaborations for culturally
appropriate and evidence-based interventions.

Frontiers in Community-Led Partnerships

The Navajo tribal government, Indian Health Service (IHS), two nonprofits
with Navajo executive directors, and an AI university-based researcher with
AI staff were critical to the success of the Four Corners American Indian
Circle of Services Collaborative. The Four Corners American Indian Circle
of Services Collaborative partners include the Na’NizhoozhiCenter (NCI), a
nonprofit alcohol and substance abuse treatment facility; the Navajo AIDS
Network, a private, not-for-profit agency with offices in Arizona and New
Mexico; the Navajo Nation Division of Health’s Community Health Worker
and Social Hygiene Programs; the Navajo Area Indian Health Service; and
the UNM Masters in Public Health Program. This project was the continuation
of a previous Health Resources and Services Administration’s Special Projects
of National Significance, awarded to the Navajo Nation in 1996. The
Four Corners American Indian Circle of Services Collaborative used a
community-based participation evaluation approach recognizing the auth-
ority of tribal government but giving NCI an essential fiscal management
and contract oversight role. An asset to cultural appropriateness and the
inclusion of culturally supported interventions was that the majority of
Four Corners American Indian Circle of Services Collaborative partners and
providers were Navajo-speaking tribal members working in Navajo-oriented
medical and social service agencies. Through extensive training by Four
Corners American Indian Circle of Services Collaborative partners, as well
as distance education, the IHS Infectious Disease Director ensured cultural
appropriateness and clinical excellence of all providers treating HIV=AIDS
patients.

EXPANDING THE FRONTIER OF HIV=AIDS CARE

Mental Health Services

Mental health services were offered to clients at IHS by a board-certified
psychiatrist using a one-stop model to enhance patient trust in confidentiality
 Tribally-Driven HIV/AIDS Health Services Partnerships 115

and eliminate the need for multiple mental health intake surveys. The
psychiatrist collected the necessary intake information, provided psychotro-
pic medication management if needed, and offered psychological counseling
services ranging from supportive to cognitive-behavioral psychotherapy in a
client-centered model. Information was provided on issues ranging from
HIV education, substance abuse prevention, good sleep hygiene, setting life
goals, healthy relationships, disclosure issues, fears of death and dying, safe
sex practices, to medication adherence. The primary goal was improved
medication adherence with reduced substance abuse especially with HAART.

HIV Primary Care

HIV care is supervised centrally from an IHS infectious disease clinic in one
of the border towns of the Navajo Nation. Care is provided to a total of 100
patients at this clinic and seven other hospitals or clinics spread across the
Navajo Nation. The infectious disease clinic has a clinical component offering
HIV primary care to persons infected with HIV, as well as a novel
pharmacist-run adherence component (Iralu et al., 2010). The IHS infectious
disease clinic collaborates with the Navajo AIDS Network (NAN) for
case-management bimonthly team care reviews and makes referrals for
substance abuse care to the NCI program. An American Academy of HIV
Medicine study guide correspondence course was offered to all HIV provi-
ders on the reservation, and most completed and passed the training. To
ensure high-quality care, the IHS infectious disease specialist conducts
annual quality assurance reviews on all HIV patient charts.

Substance Abuse Treatment

The NCI was founded in 1992 to address the problem of public intoxication
in Gallup and McKinley County, New Mexico. The agency was formed
through a collaborative effort of the Navajo Nation, Zuni Pueblo, City of
Gallup, and McKinley County. NCI offers protective custody detoxification,
shelter, and Traditional Native American residential treatment and outpatient
treatment. All are designed to be culturally appropriate to meet the needs of
AI clients. A key advantage of this design is that programs can integrate best
practices in substance abuse treatment with AI cultural healing and
traditional forms of medicine. The residential treatment program, Hiina’ah
Bits’os Society (Eagle Plume Society), is a 60-day structured program, based
on the Navajo ‘‘Beauty Way’’ philosophy that aims to teach ‘‘relatives’’
(clients) to better respect themselves. Clients are called ‘‘relatives’’ to
acknowledge the unity between the person and the problem, as well as
in keeping with the cultural principle of K’e (the clanship system) that all
Navajos are related. The NCI currently has a capacity of 35 beds.
116 B. Duran et al.

Navajo AIDS Network Case Management

NAN’s specific brand of culturally appropriate case management was the key
integrating component in the Four Corners American Indian Circle of Ser-
vices Collaborative to improve the health status and increase the life span
among clients living with HIV=AIDS. Case management has been correlated
with a better quality of life, increased adherence to HAART (Shelton, Golin,
Smith, Eng, & Kaplan, 2006), and cost effectiveness (Porche, 2000).
For the past 17 years, NAN has provided HIV=AIDS case management
and prevention services to AIs with HIV=AIDS on or near the Navajo Nation.
NAN’s comprehensive case management combines traditional Navajo (as
well as other AI, non-Navajo) cultural approaches with Western case man-
agement methods to deliver client-centered services. Two case managers
and the project director (all Navajo speakers) assessed the patient’s needs
and improved quality of life by helping to secure Social Security, federal
medical insurance, Temporary Assistance for Needy Families, food stamps,
housing, and transportation. Case managers used motivational interviewing
techniques to promote treatment adherence and service use (Foley et al.,
2005). A crucial element in NAN case management is helping to arrange or
finance traditional Navajo treatment by a medicine person. Often through
NAN referral, NCI routinely provides traditional medicine services such as
sweat lodges and healing circles based on Native American Church princi-
ples. By way of mentors, intergenerational groups, crafts, and social activi-
ties, NAN structures patient engagement activities that promote cultural
restoration, self-care, and wellness—which all alleviate stigma.
A key goal in HIV case management is medical regimen adherence. A
subpopulation of the HIV-positive AI=AN has multiple co-occurring disorders
that may include any combination of AIDS, other STDs, mental illness,
diabetes, heart disease, alcoholism, drug addiction, frequent injuries, etc.
These conditions are often further complicated by social determinants of ill
health: poverty; debt; low educational attainment; criminal justice involve-
ment; and family, housing, and food instability. AI medical and mental health
status is often overpathologized by mainstream providers who have difficulty
separating medical and mental illness issues from social service and crisis
intervention needs within the context of cultural difference (Duran & Duran,
1995). Culturally appropriate case management can help clients adhere to
complex regimens, even in the context of difficult cases and limited
resources. Case managers also help providers by aligning and navigating
patients into treatment within a multidisciplinary team context.
In addition to assessment and referrals, NAN and the Navajo Area Indian
Health Service providers meet monthly in case conferences so that case man-
agers can assist with medical management and monitoring. Through individ-
ual visits, regular support groups, and special celebrations and events, NAN
case managers and program staff provide psychosocial and cultural support
 Tribally-Driven HIV/AIDS Health Services Partnerships 117

for clients and help navigate them through a complex and culturally dispar-
ate health care delivery system.

Community-Based Participatory Evaluation

Research is viewed as suspect in many AI communities. Historically, much of
the published research has been conducted by individuals outside of the AI
community and unfamiliar with cultural values and norms. Researchers have
often denied or ignored the value of AI cultures, so that many of the research
questions and findings were less about the improved health and well-being
of indigenous peoples and more about creating the rationale for the current
trends in federal Indian policy (Kelm, 1998). Many research efforts were
used to depict AI peoples as primitive and susceptible to illness—victims
who needed to be cared for (Kelm, 1998; Waldram, 2004). This rhetoric often
led to expanded federal services, which meant increased efforts to
‘‘integrate’’ AIs (McCallum, 2005). This integration ultimately was forced
assimilation, which meant an acceptance of the traditions of the researcher’s
culture with little recognition of the inherent value in AI traditions (Vanast,
1992). Many of the health research articles served as a ‘‘roadmap’’ for coloni-
zers who used IHS to overcome difficulties of transportation and communi-
cation in more remote, previously inaccessible locations (McCallum, 2005).
In truth, much of historical research done on AI people has contributed to
the breakdown of AI life-worlds, culture, and traditions and has, therefore,
been a significant contributing factor in AI health disparities.
The Four Corners American Indian Circle of Services Collaborative team
incorporated several CBPE principles and mechanisms to overcome the
legacy mentioned. The core principles include:

1. Equitable sharing of funding resources and responsibility.

2. Frequent communication and face-to-face meetings with partners.
3. Annual retreats for team building, project review, and goal setting.
4. An AI-based conflict resolution system.
5. A commitment to hiring evaluation staff from the target population.
6. Collaborative inclusion based on a history of successful partnership and
trust.
7. A high level of commitment and urgency for project goals.
8. Respect for and=or familiarity with Navajo cultural and spiritual beliefs.

Each partner either entered the collaborative with knowledge and skills
important to the project and CBPE success or was coached and supported by
other partners to build competencies. For example, the UNM partners con-
tributed coaching and cross-training in research methods, the IHS partners
contributed clinical (medical and mental health) knowledge, and the Navajo
Nation, NAN, and NCI provided cultural knowledge and the hub of outreach,
118 B. Duran et al.

FIGURE 1 Integrated Service Model: Medical Care, Mental Health Treatment, Traditional
Medicine.

case management, and referral. This is the heart of integrated, culturally

appropriate, community-supported, and evidence-based services (Fig. 1).
A main evaluation research focus of the Four Corners American
Indian Circle of Services Collaborative project was to determine the
feasibility of integrating alcohol, drug, and mental disorder services in a
rural frontier, economically challenged geographic area. The project
hypotheses were (1) AI evaluation research has better outcomes and less
attrition with CBPE methods; (2) motivational interviewing counseling
promotes entry into mental health and substance abuse treatment; and
(3) HIV treatment access and adherence will increase with culturally
appropriate, integrated services.

METHODS

The evaluation research used a mixed-methods qualitative=quantitative

design. The client survey was conducted in a one-group, pre- and post-,
repeated measures design. Although the use of a comparison group would
have strengthened the evaluation, the Four Corners American Indian Circle
 Tribally-Driven HIV/AIDS Health Services Partnerships 119

of Services Collaborative partners and the Navajo Nation Human Research

Review Board (NNHRRB) consider a more rigorous design impossible
because of the limited access to scarce services on the Navajo Nation. A client
focus group was used to inform and clarify quantitative research findings.

Participants
The Four Corners American Indian Circle of Services Collaborative target
population was AIs with HIV=AIDS residing on and near the Navajo Nation
between June 2003 and December 2007, limited to those 18 years of age or
older. Study participants entered the evaluation sample through their case
manager or any other Four Corners American Indian Circle of Services
Collaborative provider portal (see Figure 1). The evaluation research was
approved and annually reapproved by two institutional review boards: the
NNHRRB, a tribally mandated and community-controlled board and the
UNM Human Research Review Committee.

Health Survey
Health survey data were collected on demographics, service needs, utiliza-
tion and satisfaction, co-occurring disorders, clinical and mental health sta-
tus, medical regimen adherence, and quality of life. NAN case managers
provided potential participants with a comprehensive overview of the survey
and used motivational interviewing (Rollnick, Miller, & Butler, 2008) to
answer questions and address ambivalence about the health survey process.
After a thorough consent process before conducting the survey, NAN case
managers interviewed participants in English and=or Navajo. The project
used the Patient Problem Questionnaire, an AIDS-specific variant of the Pri-
mary Care Evaluation of Mental Disorders (Spitzer et al., 1994) to determine
6-month alcohol, drug, and (other) substance abuse prevalence.

Focus Group
At the end of the fourth year, seven program clients participated in a focus
group designed to elicit information regarding the survey outcomes. The
focus group was led by the research director of the UNM evaluation team
and assisted by Navajo and Hispanic evaluation staff and students. The focus
groups used a semistructured interview guide, and data were tape-recorded,
transcribed, and analyzed using ATLAS.ti (Bryman, 2008).

Statistical Analysis
Descriptive statistics for the demographic variables, such as income,
substance abuse, and service needs were obtained from the baseline sample
120 B. Duran et al.

(N ¼ 46), round one. These variables provide an overview of the characteris-

tics of the participants. Substance abuse prevalence was cross-tabulated with
demographic variables and mental health service needs for the baseline
sample. Chi-squared tests were used to determine the significance of these
associations.
To assess the changing service needs and ongoing service utilization
patterns of the study population, a longitudinal panel survey was conducted,
and data were collected from each respondent up to five times over the life
of the project and at least 6 months from the previous interval. Univariate
logistic regression models with repeated measures were built with the vari-
able of a ‘‘round’’ (a single data point within a series of repeated observations
of the same items) as the independent variable and each of the ‘‘needs’’
variables as the dependent variable. The ‘‘needs’’ variables included mental
health services, housing services, financial assistance, food assistance,
employment assistance, clothing and household items, legal assistance, and
transportation services.

RESULTS

Demographics
Since 2002, 46 of 53 (87%) referred and approached clients chose to partici-
pate in at least one round of the survey. Reasons for declining to participate
in the interview include fear of breach of confidentiality, distrust of research,
illness, and disinterest. Sixty-five percent of the 46 individuals seeking case
management from NAN were men (n ¼ 30), 24% were women (n ¼ 11),
and 11% (n ¼ 5) were transgender. Of the interviewed sample, 50% had
more and 28% had less than a high school education.
The rural geography of the Navajo Nation is an important factor in
access and utilization of care. Seventy-two percent of clients lived in rural
frontier areas, and 26% lived on or near border towns with populations
of less than 21,000. Through self-reporting, 89% of clients reported
HIV-positive serostatus versus 11% who reported having AIDS. As a means
of protecting clients, data collectors were training in the ethical conduct of
research interviewing with an emphasis on the importance of confidential-
ity. Economic and living situation data were also obtained. The majority of
participants (70%, n ¼ 32) reported being unemployed or disabled. In terms
of their housing situation, 37% lived in their own home and 54% lived with
relatives.

Health Status
A main focus of the Four Corners American Indian Circle of Services Colla-
borative project was to determine the feasibility of integrating alcohol, drug,
 Tribally-Driven HIV/AIDS Health Services Partnerships 121

and mental disorder services in a rural frontier, economically challenged geo-

graphic area. Our sample data revealed a high prevalence of alcohol and
drug abuse, as well as other factors that may interfere with treatment adher-
ence and wellness, such as incarceration and high-risk sexual practices.
In the past 6 months, 48% (n ¼ 22) of participants were positive for alco-
hol abuse, and of those, nine were also positive for combined alcohol=drug
abuse. Marijuana was the most common illicit drug used by clients. Sixty-five
percent (n ¼ 30) of participants reported at least one instance of incarceration
in a Navajo jail, federal=state prison, or detention center (Table 1).
MSM comprised 73% (n ¼ 22) of men participating in this survey. The
results indicated that within the past 12 months, 59% (n ¼ 13) of the MSM
were sexually active and half of those reported inconsistent use of condoms
(data not shown).
Many participants reported being HIV-asymptomatic and felt their
health status was good or better than good. Among Four Corners American
Indian Circle of Services Collaborative participants, 75% participated in
HAART. At baseline, self-reported medical regimen adherence was fair, with
71% of clients (n ¼ 24) reporting no missed doses of HIV medication during
the past 4 weeks.
Chi-squared tests were used to determine the associations between each
of the two substance abuse variables: (1) alcohol abuse (p ¼ 0.035) and (2)
mental health needs. The analysis indicates that incarceration is associated
with alcohol abuse with over 60% of those incarcerated experiencing alcohol
abuse during the last 6 months. Among the nine individuals using drugs,
seven were younger than 40 years, eight had been incarcerated, and nine
were from rural locales. In our sample of HIV=AIDS clients, gender, income,
housing, educational level, work and marital status, sexual orientation, and
adherence were not associated with alcohol or drug abuse=dependence
(Table 2).

Health Service Needs and Satisfaction with Services

At baseline, the greatest needs identified in rank order by clients were finan-
cial assistance (31 of 46, 67%), transportation (24 of 46, 52%), housing (22 of
46, 48%), and food services (21 of 46, 46%). Legal assistance (7 of 46, 16%)
and household items (9 of 46, 20%) were the least needed services. More
than 70% of clients who stated they needed mental health services, food ser-
vices, household items, and financial assistance received those services.
Nearly 60% of clients who stated they needed transportation and legal assist-
ance received those services, but only 40% of those needing housing services
and employment assistance received the services. Overall, the level of satis-
faction with services was ‘‘somewhat satisfied’’ with most of the services. The
17 receiving food services and 4 receiving legal services reported being ‘‘very
satisfied’’ (Table 3).
122 B. Duran et al.

TABLE 1 Demographics (N ¼ 46)

Variables Frequency Percent

Age (years)
21–33 8 17.39
34–40 18 39.13
41–69 20 43.48
Gender
Male 30 65.22
Female 11 23.91
Transgender 5 10.87
Monthly income
$0–$500 14 30.43
$501–$800 11 23.91
$801–$1000 7 15.22
$1001–$1500 6 13.04
>$1500 8 17.39
Housing
Own apartment=house 17 36.96
Doubled up 2 4.35
Shelter 1 2.17
Living with relatives 25 54.35
Other 1 2.17
Education level
<High school 13 28.26
High school 10 21.74
>High school 23 50.00
Work status
Employed 13 28.26
Unemployed 20 43.48
Disabled 12 26.09
Missing 1 2.17
Marriage
Married 13 28.26
Previously married 6 13.04
Never married 27 58.70
Geography
Urban 12 26.09
Rural 33 71.74
Missing 1 2.17
HIV status
Asymptomatic HIV 37 80.43
Symptomatic HIV 4 8.70
AIDS 5 10.87
Alcohol abuse (past 6 months)
No 23 50.00
Yes 22 47.83
Missing 1 2.17
Drug abuse (past 6 months)
No 37 80.43
Yes 9 19.57
Other substance abuse (past 6 months)
No 23 50.00
Yes 22 47.83
Missing 1 2.17

(Continued )
 Tribally-Driven HIV/AIDS Health Services Partnerships 123

TABLE 1 Continued

Variables Frequency Percent

Incarceration
No 16 34.78
Yes 30 65.22
Jaila
No 1 3.33
Yes 29 96.67
MSMb
No 8 26.67
Yes 22 73.33
MSM 12 monthsc
No 9 40.91
Yes 13 59.09
Adherence 4 weeksd
Not once 24 70.59
Less than once a week 7 20.59
A few days a week 3 8.82
a
Reflects those incarcerated (n ¼ 30).
b
Reflects men having sex with men (n ¼ 30).
c
Reflects men having sex with men in the previous 12 months (n ¼ 22).
d
Reflects times missing HIV medication doses in the previous 4 weeks (n ¼ 34).

The results of the univariate logistic regression analysis indicate that four
of the needs variables are negatively related with the round. In most cases,
clients expressed a significantly lower need for services over time as they were

TABLE 2 Substance Abuse and Demographic Characteristics

Alcohol abuse, 6 months Drug abuse, 6 months

n Frequency (%) p-value Frequency (%) p-value

Gender
Male 30 14 (47) 7 (23)
Female 11 5 (45) 0 (0)
Transgender 5 3 (60) 0.859 2 (40) 0.118
Age
21–23 8 4 (50) 4 (50)
34–40 18 7 (39) 3 (17)
41–69 20 11 (55) 0.511 2 (10) 0.051
HIV status
Asymptomatic 37 16 (43) 6 (16)
Symptomatic 4 4 (100) 2 (50)
AIDS 5 2 (40) 0.098 1 (20) 0.063
Incarceration
Yes 30 18 (60) 8 (27)
No 16 4 (25) 0.035 1 (6) 0.096
Location
Town 12 5 (42) 0 (0)
Rural 33 17 (52) 0.498 9 (27) 0.043
124 B. Duran et al.

TABLE 3 HIV Health Service Needs and Satisfaction with Services (N ¼ 46)

In the past 12 months,

have you had a need for. . . Need (%) Received (%)a Satisfactionb

Mental health services 16 (35) 13 (81) 1.50

Food services 21 (46) 17 (81) 1.28
Household items 9 (20) 7 (78) 1.50
Financial assistance 31 (67) 22 (71) 1.68
Transportation 24 (52) 14 (58) 1.45
Legal assistance 7 (16) 4 (57) 1.00
Housing services 22 (48) 9 (41) 2.14
Employment assistance 15 (33) 6 (40) 2.10
a
Percent reflects services received of those in need (received=need ¼ %).
b
1 ¼ very satisfied; 2 ¼ somewhat satisfied; 3 ¼ somewhat dissatisfied; 4 ¼ very dissatisfied.

able to access partner services and have their needs satisfied. Over time, the
Four Corners American Indian Circle of Services Collaborative–integrated
program was able to significantly meet client needs for household and cloth-
ing items, transportation, financial assistance, and housing. Although clients
felt that they had access to mental health services, the need for those services
did not diminish over time.

Focus Group Outcome

Qualitative interview data were used to supplement data collected on the
health survey. Data from one focus group revealed that the Four Corners
American Indian Circle of Services Collaborative clients felt that a distinct
subpopulation of AIs with HIV were both adherent to HAART, yet continued
to participate in high-risk activities, specifically alcohol and drug use and
high-risk sexual behaviors. The data also revealed a unique pattern of circu-
lar migration, as these same clients reported moving to urban areas during
the winter months and returning to rural areas in the spring, when the
weather is warmer and unpaved roads are in better condition to travel.

TABLE 4 Need for Partnership Services >1 Year in Case Management (N ¼ 46)

Needs Odds ratio 95% confidence interval p-value

Household items 0.38 0.19, 0.76 0.01

Transportation 0.58 0.38, 0.90 0.02

Financial assistance 0.58 0.36, 0.93 0.02

Housing services 0.61 0.39, 0.95 0.03

Employment assistance 0.73 0.50, 1.06 0.10
Food services 0.75 0.50, 1.13 0.17
Legal assistance 0.83 0.41, 1.68 0.61
Mental health services 1.06 0.78, 1.43 0.72


p < 0.05.
 Tribally-Driven HIV/AIDS Health Services Partnerships 125

According to clients, unprotected sex always occurs within the context of

alcohol abuse. Although a portion of clients were celibate or in committed
relationships, some clients continue to engage in unprotected sex with casual
partners during bouts of drinking and ‘‘partying,’’ usually during weekend
forays into border towns. The MSM population who do not identify as gay,
and who might be engaged in heterosexual relationships, including mar-
riage, partly fuels this phenomenon.
Another subpopulation consists of relatively stable clients, usually older,
who discussed AIDS medical regimen adherence within the context of other
preventive medical care, such as cholesterol, hypertension, and diabetes
treatment. Generally, these clients entered into mental health services at
the beginning of HIV=AIDS medical treatment and worked on issues enough
to support adherence. Over time, these clients have addressed discrimination
and resistance in their families and IHS providers through familiarity and
education.
All clients feared revealing their HIV status to the general community,
and some had fear of HIV status exposure to extended family members.
Clients attributed discrimination to fundamental religious attitudes (both
Christian and indigenous Navajo), lack of knowledge, and adherence to
traditional beliefs around open-mindedness and homosexuality.

Limitations
The study is weakened by both the quasi-experimental design and the small
sample size. As stated earlier, a comparison group would have provided
stronger evidence that the intervention was responsible for the reduction
in clients’ needs over time. The same sample size may have masked associa-
tions between key demographic variables and alcohol and drug abuse and,
therefore, barriers to treatment adherence. Another limitation was the male
bias of the survey instruments. As the numbers of women presenting for
HIV treatment increased, we became aware that women-specific needs, such
as childcare, Women, Infants & Children Nutrition Program, and family ser-
vices, were not included in the survey. In addition, the mental health and
case management providers noted that same-sex domestic violence issues
were cause for noncontinuation of mental health treatment and poor regi-
men adherence. The survey, unfortunately, did not collect data on interper-
sonal violence. The largest limitation of the evaluation research is the lack of
data from HIV-positive Navajo and other AIs who are not in medical treat-
ment or case management. The population represented in these data is a
fraction of the total clients and, therefore, provide a limited client profile.
Although the limitations outlined earlier provide constraints to the data,
the authors contend that the information provided here is a significant con-
tribution to HIV-treatment literature.
126 B. Duran et al.

DISCUSSION

A large concern at the beginning of the project was that access to mental health
services would be limited due to the combination of the associated stigmas
against HIV=AIDS, MSM, and mental health services (Foley et al., 2005). The
authors are pleased that 50% of the clients received mental health services.
There was significant overlap between this 50% receiving mental health
services and the 48% of participants with alcohol and drug abuse diagnosis.
The lack of the expected inverse correlation between medication adherence
and substance abuse noted in this project may be due to the easy access to
mental health services available. The mental health provider noted clinically
that clients decreased their substance abuse during the course of their mental
health treatment. Culturally appropriate mental health services may have
provided a therapeutic alliance strong enough to prevail over the negative
influence of substance abuse on medication adherence.
The majority of the 11 clients who sought mental health services needed
only supportive counseling for fewer than 10 sessions, usually to deal with
the grief reaction to the initial diagnosis and readjustment of life goals. Clients
were quite resilient in adjusting to their new reality fairly quickly, if not
always changing their risk behaviors.
Reported high-risk sexual activities and HIV status at treatment initiation
reveal that HIV=AIDS is being spread among members on the Navajo
Nation. Secondary prevention and culturally appropriate HIV=AIDS
education activities are critical to mitigate these risks.
This intervention breaks new ground in the integration of culturally
supported and evidence-based interventions in AIDS prevention, treatment,
and evaluation. The Four Corners American Indian Circle of Services Colla-
borative is the first AI-led collaboration to test the efficacy of a case manage-
ment intervention for rural, HIV-positive AIs. These findings demonstrate the
effectiveness of culturally appropriate case management and validate the
importance of maximizing available resources in economically challenged
rural areas.
The Four Corners American Indian Circle of Services Collaborative’s
commitment to a CBPE approach enabled partners to use research to upend
the premises of colonial history through the development of equal partner-
ships with AI peoples. Research efforts that are both guided and informed
by individuals who are leaders and residents within the community offer a
foundation for improved participation, better outcomes, and lasting com-
munity capacity development and change. AI partners can use research ques-
tions and findings to ‘‘decolonize’’ the scientific and popular literature about
the ‘‘primitiveness’’ of AIs and to ‘‘indigenize’’ services.
The Four Corners American Indian Circle of Services Collaborative
represents a new frontier in services where AI-led partnerships pool
 Tribally-Driven HIV/AIDS Health Services Partnerships 127

resources for the provision of comprehensive, coordinated, and continuous

care to underserved HIV-positive AI individuals, their families, and their com-
munities. It demonstrates that a critical resource for improved health out-
comes is the commitment to, respect for, and knowledge of AI traditions
of health and wellness.

NOTES

1. The Navajo Nation is defined as the tribal government representing enrolled Navajo people living
on or in proximity to the federally designated Navajo Indian Reservation; the Navajo Nation can also refer
to the Navajo people, as well as the lands that the Navajo people occupy.
2. ‘‘Frontier’’ is a National Institutes of Health definition of rural counties and subcounties using a
weighted average of low population density (0 to 20 people per square mile), long distances from markets
and services (30 to 90 þ miles), and long travel times to markets and services (30 to 90 þ minutes). Most of
the Navajo Nation falls under this definition of ‘‘frontier.’’ When used in this specific context, it will be noted
as ‘‘rural frontier’’ in this article. For details, see http://www.frontierus.org/documents/consensus.htm.
3. The CDC’s epidemiological database does not parse out American Indians and Alaska Natives.
While this paper focuses solely on American Indians, leaving out Alaska Native in the statistical data would
be misleading.
4. The ‘‘Colonial Health Deficit’’ is inspired by the term ‘‘Slave Health Deficit’’ used in the
report ‘‘Racism in Medicine and Health Parity for African Americans: ‘The Slave Health Deficit’ ’’ by the
National Medical Association, 2002. For details, see http://www.nmanet.org/images/uploads/
Racism%20in%20Medicine.pdf.

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