The categorization of articles in the table demonstrates a growing research effort on many dimensions of HIV/AIDS about AI/AN populations; even so, the number of articles is small, and randomized control studies are all but absent. Nonetheless, many of these articles provide information that may be applicable to the prevention and control of other STDs in this population, for example, sexual risk factors among AI/ANs, or community approaches to intervention.
As in the national population, the majority of STDs among AI/ANs occur among young people. Among AI/ANs, 68% of all chlamydia cases, and 60% of all gonorrhea cases occur among those aged 15 to 24.17 In our review, we found one large study on sexual risk-taking among AI/AN youth. In 2000–2001, the Bureau of Indian Affairs (BIA) conducted a survey on risk-taking behavior with over 5600 high school students enrolled in BIA schools.100 This study, using comparable questions to the national Youth Risk Behavior Study (YRBS),101 found that 59% of high-school students reported having had sex, compared with 46% of the national sample, that 24% reported having 4 or more partners during their lifetime versus 14% of the national sample, and that 56% of those sexually active used a condom at last intercourse versus 58% nationally. (Note that important methodological differences between the two studies precluded significance testing of differences.) Of those who had already had sex, 11% of AI/AN youth reported initiating sex before the age of 13, compared with 7% nationally.100,101 The results indicate that sexual risk-taking is comparatively high among AI/AN youth, even though condom use appears to be roughly equivalent. An earlier study (1992), also based on a survey with BIA high school students, found similar patterns.102 Unfortunately, very little ethnographic data exists on the context of decision-making that produces such numbers. One report found that youth indicate that an environment of risk, including level of exposure to substance use, perceived sexual activity of peers, and role models in families or communities, were key to their sexual decision-making context.103
STD prevention and control activities are sparse in AI/AN communities, and, as in peer-reviewed articles, HIV/AIDS appears to have received greater attention than other STDs. We have summarized the results of our search for reports and guides, descriptions of model programs or activities, and electronic resources in Table 3.
Several potentially effective models do exist, but systematic evaluations of the effectiveness are rare. Screening for STDs at clinics and hospitals appears to occur more regularly for women than for men, but may also inappropriately target older age groups.9 Although a number of clinic-based HIV training programs specifically designed for AI/AN communities exist,121–124 clinical HIV services may not always be offered because of the expense or lack of expertise.125 Comprehensive program assessments, grounded in the particular context of each AI/AN community, are urgently needed.105,126
A number of programs and data-collection initiatives exist that are not documented in peer-reviewed publications, but contribute to the base of our knowledge of STD prevention and control among AI/ANs.104 Tribal epidemiology centers represent multi-institutional cooperative efforts to coordinate monitoring and prevention activities at local levels.127 Several of these centers have identified STDs as a major focus of program and surveillance activities. The Northwest Tribal Epidemiology Center initiative entitled Project Red Talon is designed to provide member tribes with education, training, and technical assistance for the prevention and treatment of STDs.107 The project includes a regional STD profile and needs assessment; technical assistance to tribal health care advocates; and a rolling implementation of new screening and treatment strategies.126 The Inter-Tribal Council of Arizona has developed an HIV/AIDS-focused strategy that is now in the process of national scale-up.109 Tribal and pan-Native urban programs are also increasingly active, both in targeted programmatic activities117 and in efforts to increase coordination and cooperation with state and federal agencies.111,116 In recognition of the potential synergy of such collaborative efforts, the CDC has undertaken initiatives which provide funding directly to tribes, instead of to states in which tribes are located.127 Such steps are vitally important in channeling resources so that they may be most efficiently used in areas with the greatest need. Unfortunately, the continuation of this type of funding is not assured.128
The epidemiologic evidence suggests that AI/ANs have elevated case rates of chlamydia, gonorrhea, and syphilis when compared with the national population, and that in areas of relative AI/AN concentrations, the burden is even greater.21 The prevalence of AIDS was not found to be elevated among AI/ANs. However, the association of chlamydia, gonorrhea, and syphilis with HIV transmission places them at risk for progression to this condition. Indeed, extant literature on STDs among AI/ANs is dominated by a focus on HIV/AIDS. Reports, guides, and resources show a similar orientation. The distribution of articles (and resources) is perhaps not surprising given the consequences and visibility of HIV/AIDS relative to other STDs, and the availability of funding to support research in this area.
Clearly, substantial overlap exists for risk factors related to HIV/AIDS and other STDs. However, research on non-HIV/AIDS STDs continues to be particularly valuable for at least 3 reasons: (1) it provides specific information on parameters of these diseases (e.g., community perception of STD risk and consequences) not revealed in HIV/AIDS-focused work; (2) it addresses a major risk factor for HIV/AIDS in a vulnerable population; and (3) chlamydia, gonorrhea, and syphilis require clinical and epidemiologic management distinct from that for HIV/AIDS, and the successful implementation of these protocols for this population is paramount.
Our review indicates that little is known about the application and efficacy of STD screening, treatment, and partner management programs specific to AI/AN communities. Factors that contribute to disparities that affect these communities and need to be considered in assessing these parameters include geographic isolation, poor access to health services, insufficient screening and partner management services, and unique social norms, stigma, and gender dynamics. Youth comprise a substantial proportion of AI/ANs contracting STDs, which poses specific challenges to local prevention activities. Tribal and state laws vary widely (and are frequently contradictory) regarding STD screening or treatment services for minors; definitions for, and enforcement of, mandatory statutory rape reporting; and, increasingly, STD educational activities.
Improvements in STD systems of care for AI/AN populations will occur only if they reflect the local cultural framework of health, healing, and understanding of sexual relationships. Toward this end, we identify 6 areas of future research and programmatic focus: (1) behavioral and disease surveillance systems appropriate for effective localized monitoring and response; (2) AI/AN youth access and treatment policies and procedures; (3) culture- and context-specific partner management systems; (4) existing traditions of sexual health; (5) scientifically rigorous investigation of culturally appropriate prevention and control strategies; and (6) adaptation and evaluation of proven interventions.
The daunting epidemiologic profile of STDs among AI/ANs and the high cost associated with these conditions and their sequelae emphasize the profound need for successful models of intervention. STDs are preventable and many are curable; effective programs could eliminate or narrow extant disparities and substantially reduce health care costs. The cultural context of the STD epidemiology of the AI/AN population poses the challenge to the health community—public and private—for urgent, meaningful, and systematic attention.
1. CDC. Sexually Transmitted Disease Surveillance 2004. Atlanta, GA: Department of Health and Human Services, CDC, Division of STD Prevention; 2005.
2. Division of STD Prevention. Tracking the Hidden Epidemics: Trends in STDs in the United States 2000. Atlanta, GA: Department of Health and Human Services; 2000:8.
3. Eng TR, Butler WT. The Hidden Epidemic: Confronting Sexually Transmitted Diseases. Washington, DC: National Academy Press; 1997.
4. Johnson RE, Newhall WJ, Papp JR, et al. Screening test to detect Chlamydia trachomatis
and Neisseria gonorrhoeae
infections—2002. MMWR Recomm Rep 2002; 51(RR15):1–27.
5. Cohen MS, Hoffman IF, Royce RA, et al. Reduction of concentration of HIV-1 in semen after treatment of urethritis: Implications for prevention of sexual transmission of HIV-1. Lancet 1997; 349:1868–1873.
6. McClelland RS, Wang CC, Mandaliya K, et al. Treatment of cervictis is associated with decreased cervical shedding of HIV-1. AIDS 2001; 15:105–110.
7. Chesson HW, Blandford JM, Gift TL, Guoyu T, Irwin KL. The estimated direct medical cost of sexually transmitted diseases among American youth, 2000. Perspect Sex Reprod Health 2004; 36:11–19.
8. Miller WC, Ford CA, Morris M, et al. Prevalence of chlamydial and gonococcal infections among young adults in the United States. JAMA 2004; 291:2229–2235.
9. Cheek JE, Shelby LK, de Ravello L, Blasini-Alcivar L. Sexually Transmitted Disease 2002 Annual Report. Indian Health Service and Centers for Disease Control and Prevention; 2003.
10. U.S. Census Bureau. Census 2000 Summary Files 1, 2, 3 (SF1, SF2, SF3). 2002.
12. U.S. Department of Health and Human Services. Trends in Indian Health 1998–1999. Rockville, MD: Department of Health and Human Services; 2001.
13. Duncan GJ, Raudenbush SW. Neighborhoods and adolescent development: How can we assess the links? Paper presented at: Does it take a village? Community Effects on children, adolescents, and families, Pennsylvania State University, 1998.
14. Bailey SL, Pollock NK, Martin CS, Lynch KG. Risky sexual behaviors among adolescents with alcohol use disorders. J Adolesc Health 1999; 25:179–181.
15. Kaufman CE, Beals J, Mitchell CM, LeMaster PL, Fickenscher A. Stress, trauma, and risky sexual behavior among American Indians in young adulthood. Cult Health Sex 2004; 6:301–318.
16. Centers for Disease Control and Prevention. Trends in Reportable Sexually Transmitted Disease in the United States, 2004. Atlanta, GA: Department of Human Health and Services; 2005.
17. Centers for Disease Control and Prevention. Rates per 100,000 population by race/ethnicity, age group, and sex, United States, 2000–2004: Chlamydia, gonorrhea, and primary and secondary syphilis (Tables 11B, 21B, and 34B). Available at http://www.cdc.gov/std/stats/tables/
. Accessed May 12, 2006.
18. Centers for Disease Control and Prevention. Cases of HIV Infection and AIDS in the United States, 2003, 2004. Vol 15.
19. Centers for Disease Control and Prevention. Cases of HIV Infection and AIDS in the United States, by race/ethnicity, 1998–2002, 2003. Vol 10 (No. 1).
21. Wong D, Swint E, Paisano EL, Cheek JE. Indian Health Surveillance Report–Sexually Transmitted Diseases, 2004. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, and Indian Health Service; 2006.
24. Wong D. Syphilis outbreak on (tribal name), 2000–2004. Report of the Epidemic Intelligence Service of the Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia. Unpublished memo, 2004.
26. Centers for Disease Control and Prevention. Cases of HIV infection and AIDS in the United States, by race/ethnicity, 2000–2004. HIV/AIDS Surveill Rep 2006; 12:1–24.
27. McNaghten AD, Neal JJ, Li J, Fleming PL. Epidemiologic profile of HIV and AIDS among American Indians/Alaska Native in the USA through 2000. Ethn Health 2005; 10:57–71.
28. Steenbeek A. A holistic approach in preventing sexually transmitted infections among First Nations and Inuit adolescents in Canada. J Holist Nurs 2004; 22:254–266.
29. Shields SA, Wong T, Mann J, et al. Prevalence and correlates of chlamydia infection in Canadian street youth. J Adolesc Health 2004; 34:384–390.
30. Thoroughman DA, Frederickson D, Cameron D, Shelby LK, Cheek JE. Racial misclassification of American Indians in Oklahoma state surveillance data for sexually transmitted diseases. Am J Epidemiol 2002; 155:1137–1141.
31. Patrick DM, Rekart ML, Jolly A, et al. Heterosexual outbreak of infectious syphilis: Epidemiological and ethnographic analysis and implications for control. Sex Transm Infect 2002; 78(Suppl 1):i164–i169.
32. Speier TL. Community well being and infectious diseases among Alaska Native communities in the Chugach region. Int J Circumpolar Health 2001; 60:659–675.
33. Jolly AM, Muth SQ, Wylie JL, Potterat JJ. Sexual networks and sexually transmitted infections: A tale of two cities. J Urban Health 2001; 78:433–445.
34. Fisher DG, Fenaughty AM, Paschane DM, Cagle HH. Alaska Native drug users and sexually transmitted disease: Results of a five-year study. Am Indian Alsk Native Ment Health Res 2000; 9:47–57.
35. Wylie JL, Jolly A. Patterns of chlamydia and gonorrhea infection in sexual networks in Manitoba, Canada. Sex Transm Dis 2001; 28:14–24.
36. Schiff M, Becker TM, Masuk M, et al. Risk factors for cervical intraepithelial neoplasia in Southwest American Indian women. Am J Epidemiol 2000; 152:716–726.
37. Calzavara LM, Bullock SL, Myers T, Marshall VW, Cockerill R. Sexual partnering and risk of HIV/STD among Aboriginals. Can J Public Health 1999; 90:186–191.
38. Fenaughty AM, Fisher DG, Cagle HH, Stevens S, Baldwin JA, Booth R. Sex partners of Native American drug users. J Acquir Immune Defic Syndr Hum Retrovirol 1998; 17:275–282.
39. Kenney JW. Ethnic differences in risk factors associated with genital human papillomavirus infections. J Adv Nurs 1996; 23:1221–1227.
40. Aguilera S, Plasencia AV. Culturally appropriate HIV/AIDS and substance abuse prevention programs for urban Native youth. J Psychoactive Drugs 2005; 37:299–304.
41. Gilley BJ, Co-Cke JH. Cultural investment: Providing opportunities to reduce risky behavior among gay American Indian males. J Psychoactive Drugs 2005; 37:293–298.
42. Scott KD, Gilliam A, Braxton K. Culturally competent HIV prevention strategies for women of color in the United States. Health Care Women Int 2005; 26:17–45.
43. Duran B, Walters KL. HIV/AIDS prevention in “Indian Country”: Current practice, indigenist etiology models, and postcolonial approaches to change. AIDS Educ Prev 2004; 16:187–201.
44. Majumdar BB, Chambers TL, Roberts J. Community-based, culturally sensitive HIV/AIDS education for Aboriginal adolescents: Implications for nursing practice. J Transcult Nurs 2004; 15:69–73.
45. Mitchell CM, Kaufman CE, Beals J, The pathways of choice and healthy ways project teams. Equifinality and multifinality as guides for preventive interventions: HIV risk/protection among American Indian young adults. J Prim Prev 2004; 25:491–510.
46. Sileo TW, Gooden MA. HIV/AIDS prevention education: Considerations for American Indian/Alaska Native youth. J HIV/AIDS Prev Child Youth 2004; 6:47–64.
47. Vernon I, Jumper-Thurman P. Prevention of HIV/AIDS in native American communities: Promising interventions. Public Health Rep 2002; 117(Suppl 1):S96–S103.
48. Tafoya T. Unmasking Dashkayah: Storytelling and HIV prevention. Am Indian Alsk Native Ment Health Res 2000; 9:53.
49. Baldwin JA, Maxwell CJ, Fenaughty AM, Trotter RT, Stevens SJ. Alcohol as a risk factor for HIV transmission among American Indian and Alaska Native drug users. Am Indian Alsk Native Ment Health Res 2000; 9:1–17.
50. Klein D, Williams D, Wibrodt J. The collaboration process in HIV prevention and evaluation in an urban American Indian clinic for women. Health Educ Behav 1999; 26:239–249.
51. Baldwin JA, Rolf JE, Johnson J, Bosers J, Benally C, Trotter RT. Developing culturally sensitive HIV/AIDS and substance abuse prevention curricula for Native American youth. J Sch Health 1996; 66:322–327.
52. Brassard P, Smeja C, Valverde C. Needs assessment for an urban Native HIV and AIDS prevention program. AIDS Educ Prev 1996; 8:343–351.
53. Stevens S, Estrada AL, Glider PJ, McGrath RA. Ethnic and cultural difference in drug-using women who are in and out of treatment. Drugs Soc 1998; 13:81–95.
54. Hamill S, Dickey M. Cultural competence; what is needed in working with Native Americans with HIV/AIDS? J Assoc Nurses AIDS Care 2005; 16:64–69.
55. Greabell L, Cordes P, Klein SJ. HIV/AIDS and Native Americans: The health departments' response. J Psychoactive Drugs 2005; 37:267–272.
56. Speier TL. Special projects of national significance and the Alaska Tribal health system: An overview of the development of a best practice model for HIV/AIDS care and treatment in Alaska. J Psychoactive Drugs 2005; 37:305–311.
57. Vernon I, Jumper-Thurman P. The changing face of HIV/AIDS among Native populations. J Psychoactive Drugs 2005; 37:247–255.
58. Hall HI, Li J, McKenna MT. HIV in predominantly rural areas of the United States. J Rural Health 2005; 21:245–253.
59. Dean HD, Steele CB, Satcher AJ, Nakashima AK. HIV/AIDS among minority races and ethnicities in the United States, 1999–2003. J Natl Med Assoc 2005; 97(7 Suppl):5S–12S.
60. Bertolli J, McNaghten AD, Campsmith M, et al. Surveillance systems monitoring HIV/AIDS and HIV risk behaviors among American Indians and Alaska Natives. AIDS Educ Prev 2004; 16:218–237.
61. Dallas C. How scholarly nursing literature addresses health disparities for racial/ethnic minority men. ABNF J 2004; 15:10–14.
62. Diamond C, Davidson A, Sorvillo F, Buskin S. HIV-infected American Indians/Alaska Natives in the Western United States. Ethn Dis 2001; 11:633–644.
63. Lynch M, Pugh K. Uneven ground: HIV in women of color. Adv Nurse Pract 2000; 9:44–48.
64. Weaver HN. Through indigenous eyes: Native Americans and the HIV epidemic. Health Soc Work 1999; 24:27–34.
65. Foley K, Duran B, Morris P, et al. Using motivational interviewing to promote HIV testing at an American Indian substance abuse treatment facility. J Psychoactive Drugs 2005; 37:321–329.
66. Nebelkopf E, Penagos M. Holistic native network: Integrates HIV/AIDS, substance abuse, and mental health services for Native Americans in San Francisco. J Psychoactive Drugs 2005; 37:257–264.
67. Simoni JM, Sengal S, Walters KL. Triangle of risk: Urban American Indian women's sexual trauma, injection drug use, and HIV sexual risk behaviors. AIDS Behav 2004; 16:33–45.
68. Miller C, Wood E, Spittal PM, et al. The future face of coinfection: Prevalence and incidence of HIV and hepatitis C virus coinfection among young injection drug users. J Acquir Immune Defic Syndr 2004; 36:743–749.
69. Kerr T, Wood E, Small D, Palepu A, Tyndall MW. Potential use of safer injecting facilities among injection drug users in Vancouver's downtown Eastside. Can Med Assoc J 2003; 169:759–763.
70. Craib KJP, Spittal PM, Wood E, et al. Risk factors for elevated HIV incidence among aboriginal injection drug users in Vancouver. Can J Public Health 2003; 168:19–24.
71. Martin JD, Mathias RG, Sarin C, Byrne SE. HIV and hepatitis B surveillance in First Nations alcohol and drug treatment centres in British Columbia, Canada. Int J Circumpolar Health 2002; 61:104–109.
72. Stevens SJ, Estrada AL, Estrada BD. HIV drug and sex risk behaviors among American Indian and Alaska Native drug users: Gender and site differences. Am Indian Alsk Native Ment Health Res 2000; 9:33–47.
73. Reynolds GL, Fisher DG, Estrada AL, Trotter R. Unemployment, drug use, and HIV risk among American Indian and Alaska Native drug users. Am Indian Alsk Native Ment Health Res 2000; 9:17–33.
74. Martin JD, Mathias RG. HIV and hepatitis B surveillance in First Nations alcohol and drug treatment centers in Br Columbia, Canada. Int J Circumpolar Health 1998; 57(Suppl 1):280–284.
75. Goddard G, Brown C, Ahmad A-SG. Oral disease prevalence among HIV-positive American Indians in an urban clinic. J Psychoactive Drugs 2005; 37:313–319.
76. Bien MB. Art therapy as emotional and spiritual medicine for Native Americans living with HIV/AIDS. J Psychoactive Drugs 2005; 37:261–292.
77. Ashman JJ, Perez-Jimenez D, Marconi K. Health and support service utilization patterns of American Indians and Alaska Natives diagnosed with HIV/AIDS. AIDS Educ Prev 2004; 16:238–249.
78. Barney DD, Rosenthal CC, Speier TL. Components of successful HIV/AIDS case management in Alaska Native Villages. AIDS Educ Prev 2004; 16:202–217.
79. Nebelkopf E, King J. A holistic system of care for Native Americans in an urban environment. J Psychoactive Drugs 2003; 35:43–52.
80. Oggins J. Notions of HIV and medication among multiethnic people living with HIV. Health Soc Work 2003; 28:53–62.
81. Bouey PD, Duran BE. The Ahalaya case-management program for HIV-infected American Indians, Alaska Natives, and Native Hawaiians: Quantitative and qualitative evaluation of impacts. Am Indian Alsk Native Ment Health Res 2000; 9:36–52.
82. Duran BE, Bulterys M, Iralu J, Graham Ahmed Edwards CM, Edwards A, Harrison M. American Indians with HIV/AIDS: Health and social service needs, barriers to care, and satisfaction with services among a Western tribe. Am Indian Alsk Native Ment Health Res 2000; 9:22–35.
83. Wyatt GE, Moe A, Guthrie D. The gynecological, reproductive, and sexual health of HIV-positive women. Cultur Divers Ethnic Minor Psychol 1999; 5:183–196.
84. Saylors K, Daliparthy N. Native women, violence, substance abuse and HIV risk. J Psychoactive Drugs 2005; 37:273–280.
85. McKeown I, Reid S, Orr P. Experiences of sexual violence and relocation in the lives of HIV infected Canadian women. Int J Circumpolar Health 2004; 63(Suppl 2):399–404.
86. Morrison-Beedy D, Carey MP, Lewis BP, Aronowitz T. HIV risk behavior and psychological correlates among Native American women: An exploratory investigation. J Womens Health Gend Based Med 2001; 10:487–494.
87. Mill JE. Describing an explanatory model of HIV illness among aboriginal women. Holist Nurs Pract 2000; 15:42–56.
88. Walters KL, Simoni JM, Harris C. Patterns and predictors of HIV risk among urban American Indians. Am Indian Alsk Native Ment Health Res 2000; 9:1–21.
89. Harlow LL, Prochaska JO, Redding CA, et al. Stages of condom use in a high HIV-risk sample. Psychol Health 1999; 14.
90. Calzavara LM, Burchell AN, Myers T, Bullock SL, Escobar M, Cockerill R. Condom use among aboriginal people in Ontario, Canada. Int J STD AIDS 1998; 9:272–279.
91. Mitchell CM, Beals J, Kaufman CE, and the Pathways of Choice and Healthy Ways Project Teams. Alcohol use, outcome expectancies, and HIV risk status among American Indian young adults: A latent growth curve model with parallel processes. Journal of Youth and Adolescence (In press).
92. Mitchell CM, Kaufman CE, Beals J, Pathways of Choice and Healthy Ways Project Team. Identifying diverse HIV risk groups among American Indian young adults: The utility of cluster analysis. AIDS Behav 2004; 8:263–275.
93. Mitchell CM, Kaufman CE, The Pathways of Choice and Healthy Ways Project Teams. Structure of HIV knowledge, attitudes, and behaviors among American Indian young adults. AIDS Educ Prev 2002; 14:381–398.
94. Ramirez JR, Crano WD, Quist R, Burgoon M, Alvaro EM, Grandpre J. Effects of fatalism and family communication on HIV/AIDS awareness variations in Native American and Anglo parents and children. AIDS Educ Prev 2002; 14:29–40.
95. Poiesz BJ, Papsidero LD, Ehrlich G, et al. Prevalence of HTLV-I-associated T-cell lymphoma. Am J Hematol 2001; 66:32–38.
96. Iyer RK, Kim PS, Bando JM, Lu KV, Gregg JP, Grody WW. A multiethnic study of Delta32ccr5 and ccc2b-V64I allele distribution in four Los Angeles populations. Diagn Mol Pathol 2001; 10:105–110.
97. Clarke JN, Fridman DB, Hoffman-Goetz L. Canadian aboriginal people's experiences with HIV/AIDS as portrayed in selected English language aboriginal media. Soc Sci Med 2005; 60:2169–2180.
98. Hoffman-Goetz L, Shannon C, Clarke JN. Chronic disease coverage in Canadian aboriginal newspapers. J Health Commun 2003; 8:475–488.
99. Tseng AL. Anonymous HIV testing in the Canadian aboriginal population. Can Fam Physician 1996; 42:2341–2344.
100. Everett-Jones S, Shaughnessy L, Branum C. Youth Risk Behavior Survey of High School Students Attending Bureau Funded Schools. Bureau of Indian Affairs Office of Indian Education Programs in conjunction with the Centers for Disease Control; 2001.
101. Grunbaum J, Kann L, Kinchen S, et al. Youth risk behavior surveillance–United States, 2001. MMWR 2002; 51:SS–4. Atlanta, GA: Center for Disease Control and Prevention; 2002:64.
102. Blum RW, Harmon B, Harris L, Bergeisen L, Resnick MD. American Indian–Alaska Native youth health. JAMA 1992; 267:1637–1644.
103. Satter DE, Zubiate A, Gatchell M. National Native American AIDS prevention center needs assessment: Focus groups series on young native adults and sexual health. Los Angeles, CA: UCLA Center for Health Policy Research; 2004.
105. Blasini-Alcivar L, Barrow R, Byrum D, Frick D, Mosure D. Chlamydia Program Assessment Report for Rosebud Comprehensive Health Care Facility, Rosebud, South Dakota. Atlanta: Division of STD Prevention, Program Development and Support Branch; 2004.
106. University of Oklahoma Research and Evaluation Center Staff. HRSA SPNS AI/AN Grantee Projects Case Study Protocol (Draft) 2004.
107. Red Talon STD/HIV Coalition. STD/HIV Tribal Action Plan: A Three-Year Strategic Plan for the Tribes of Idaho, Oregon, and Washington. Portland, OR: Northwest Portland Area Indian Health Board; 2006.
112. National Native American AIDS Prevention Center (NNAAPC). Oakland, CA. Available at: http://www.nnaapc.org
. Accessed June 21, 2006.
114. Native American Health Center—Family Child and Guidance Center. Holistic Native Network. San Francisco, CA. Available at: http://www.nativehealth.org/
. Accessed June 21, 2006.
115. American Indian Community House. New York, NY. Available at: http://www.aich.org
. Accessed June 21, 2006.
117. Oglala Lakota Nation Wellness Team. Pine Ridge, SD; 2006.
118. Orbis Associates. Circle of Life HIV/AIDS and STD Prevention Curriculum. Washington, D.C.: Orbis Associates; 2002.
119. Mangum A, Green Rush A, Sanabria V. HIV Prevention with Native American Youth: A Program Planning Manual: NNAAPC; 1994.
120. Native Communities HIV/STD Prevention Guidelines Task Force. HIV/STD Prevention Guidelines for Native American Communities: American Indians, Alaska Natives, and Native Hawaiians. Bloomington, IN: Rural Center for HIV/STD Prevention; 2004.
121. Bradley-Springer L, Oropeza L, Corwin MA, Rotach E, Kuali'i C. Native American HIV Care: A Training Platform. Denver, CO: Mountain Plains AIDS Education and Training Center, National Native Am AIDS Prevention Center, and the Florida/Caribbean AIDS Education and Training Center; 2004.
122. Oropeza L, Bradley-Springer L, Johnson S. HIV/AIDS Prevention Early Intervention and Health Promotion: A Self-Study Module for Health Care Providers Serving Native Americans. Denver, CO: Mountain Plains AIDS Education and Training Center and Native American AIDS Prevention Center; 2005.
123. The American Red Cross TAC. American Indians Decision to Survive. Tulsa: American Red Cross National Headquarters; 1996.
124. South Puget Sound Intertribal Agency and Northwest AIDS Education and Training Center. Assessing HIV and other STI risk in Am Indian/Alaska Native communities. Available at http://www.spipa.org/expanding.shtml
. Accessed September 26, 2006.
125. National Alliance of State and Territorial AIDS Directors. Native Americans and HIV/AIDS: Key Issues and Recommendations for Health Departments; November, 2004.
126. Craig Rushing S, Mondeaux F, Lane L. Red Talon STD Profile: STD Treatment and Prevention Capacity within Idaho, Oregon, and Washington Tribes. Portland, OR: Northwest Portland Area Indian Health Board, Project Red Talon; 2005.
127. Department of Health and Human Services. Epidemiology Grant Program for American Indians/Alaska Natives. Notice of Competitive Cooperative Agreement Applications. Vol 69. Department of Health and Human Services: Federal Register: Doc 04-14647; 2004:38907–38911.
128. National Coalition of STD Directors. Preventing STDs in Indian country: A call for collaboration, unpublished data.