Explore the vast range of titles available.

In recent years, the Department of Veterans Affairs health care system has mounted a response to hepatitis C that should be the envy of any health system. On the other hand, the Indian Health Service is struggling to meet the needs of its patients with hepatitis C.

Compared to non-Indigenous communities, American Indian/Alaska Native (AI/AN) people are inequitably impacted by HIV, yet few data are available on barriers to pre-exposure prophylaxis (PrEP) use in this population. This study sought to examine PrEP knowledge, attitudes, and perceived barriers to use among AI/AN people in the United States. A cross-sectional, online survey was administered from January-May 2023 to respondents ≥ 16 years of age who identified as AI/AN. The survey assessed sociodemographic characteristics, PrEP knowledge, attitudes towards PrEP, and experiences with and barriers to PrEP use. Sociodemographic correlates of PrEP knowledge and attitudes were identified using bivariable and multivariable regression models. The survey enrolled 403 participants and 354 (87.8%) completed all questions. Respondents had relatively low PrEP knowledge (mean score 4.0 of 9, standard deviation [SD] 3.0). Few (7%) had ever used PrEP. Mean scores on the stigma scales were 2.1 of 5 for stigmatizing PrEP attitudes (SD 0.7), 2.4 of 5 for anticipated stigma (SD 0.56), and 3.0 of 5 for perceived stigma (SD 0.38). Among non-users, 43.1% were not sure if they would be able to get a PrEP prescription if they desired, and 2.7% believed they would not be able to get one. The most common perceived barriers were not knowing where to get PrEP (54.7%) and concerns around discomfort, judgement, and privacy at the health facility (27.3%). In adjusted models, living on tribal/reservation lands was significantly associated with lower PrEP knowledge, higher stigmatizing attitudes, and higher anticipated stigma, and lower PrEP knowledge was associated with higher stigmatizing attitudes and anticipated stigma. Age, gender identity, sexual orientation, urban residence, and strength of connection to indigenous culture were also significantly correlated with one or more outcomes. Our findings underscore the need for widespread sensitization about PrEP in Indigenous communities and for strategies to improve PrEP access and reduce stigma from providers and community members.

Objectives Indian Health Service (IHS) screening rates for Chlamydia trachomatis are lower than national rates of chlamydia screening in the Southwest. We describe and evaluate the effect of a public health intervention consisting of electronic health record (EHR) reminders to alert health care providers to screen for chlamydia at an IHS facility. We also conducted an awareness presentation among health care providers on chlamydia screening. Methods We conducted our intervention from November 1, 2013, through October 31, 2015, at an IHS facility in the Southwest. We implemented algorithms that queried database values to assess chlamydia screening performance in 6 clinical departments. We presented data on the screening performance of clinical departments and health care providers (de-identified) in the awareness presentations. We re-queried database values 1 and 2 years after implementation of the EHR reminder intervention to evaluate before-and-after screening rates, comparing data among all patients and among female patients only. Results We found small, sustained relative increases in chlamydia screening rates during the 2012-2015 evaluation period: 20.8% pre-intervention to 24.9% and 24.2% one and two years postintervention, respectively, across all patients; 32.3% preintervention to 36.6% and 35.6% one and two years postintervention, respectively, among female patients. Increases in clinical department–specific screening rates varied and were most prominent in internal medicine (35.8% preintervention to peak 65.8% postintervention). The 1 clinic (obstetrics–gynecology) that did not receive an awareness presentation showed a consistent downward trend in screening rates, although absolute rates were consistently higher in that clinic than in other clinics. Conclusions Awareness presentations that offer feedback to health care providers on screening performance, heighten provider awareness of the importance of chlamydia screening, and promote development of novel provider-initiated screening protocols may help to increase screening rates when combined with EHR reminders.

The Indian Health System is poorly resourced and understaffed. Now is a promising time to reflect on big solutions for fostering a transformative, rather than transactional, relationship between the federal government and tribal nations.

Medicaid, the state-level public insurance in the United States, has widely differing criteria treatment for hepatitis C virus (HCV) such as stage of liver fibrosis, documented sobriety, and specialist consultation. In a rural health network, facilities located in two less restrictive states prescribed HCV drugs at a significantly higher rate than two more restrictive states (rate ratio 4.7, CI 2.6–8.5). Prescription rates per population were highly associated with HCV treatment policies.

Objectives: The objectives of this study were to use Indian Health Service (IHS) data from electronic health records to analyze human immunodeficiency virus (HIV) diagnoses among American Indian/Alaska Natives (AI/ANs) and to identify current rates and trends that can support data-driven policy implementation and resource allocation for this population. Methods: We analyzed provider visit data from IHS to capture all AI/AN patients who met a definition of a new HIV diagnosis from 2005 through 2014 by using International Classification of Diseases, Ninth Revision, Clinical Modification codes. We calculated rates and trends of new HIV diagnoses by age, sex, region, and year per 100 000 AI/ANs in the IHS user population. Results: A total of 2273 AI/ANs met the definition of newly diagnosed with HIV from 2005 through 2014, an average annual rate of 15.1 per 100 000 AI/ANs. Most (356/391) IHS health facilities recorded at least 1 new HIV diagnosis. The rate of new HIV diagnoses among males (21.3 per 100 000 AI/ANs) was twice as high as that among females (9.5 per 100 000 AI/ANs; rate ratio = 2.2; 95% confidence interval, 2.1-2.4); by age, rates were highest among those aged 20-54 for males and females. By region, the Southwest region had the highest number (n = 1016) and rate (19.9 per 100 000 AI/ANs) of new HIV diagnoses. Overall annual rates of new HIV diagnoses were stable from 2010 through 2014, although diagnosis rates increased among males (P < .001) and those aged 15-19 (P < .001), 45-59 (P < .001), and 50-54 (P = .01). Conclusions: New HIV diagnoses, derived from provider visit data, among AI/ANs were stable from 2010 through 2014. AI/ANs aged 20-54, particularly men, may benefit from increased HIV prevention and screening efforts. Additional services may benefit patients in regions with higher rates of new diagnoses and in remote settings in which reported HIV numbers are low.

Background: American Indian/Alaska Natives (AI/ANs) are disproportionately affected by hepatitis C virus (HCV), with more than double the national rate of HCV-related mortality as well as the highest rates of acute HCV. The “cascade of care” for HCV consists of screening, confirmation, treatment, and sustained virologic clearance (SVR)/cure. At each stage of this process, patients can be lost to follow-up. Federal health care facilities in an administrative area of the Indian Health Service conducted a review to identify and address gaps in HCV treatment. Facilities generally treated HCV with a strong pharmacy component using a collaborative practice agreement and HCV telehealth services to external specialists. Methods: All facilities had a pharmacist HCV program point of contact. Each pharmacist conducted a chart review of HCV patients and submitted aggregate results on HCV antibody status, HCV confirmation testing, stage of liver disease, initiation of treatment, and SVR/cure. Each facility also ranked current barriers to scaling up HCV treatment services from a defined list of options. Results: Of 1789 HCV antibody positive patients, 77% (1381) had a confirmation test, of which 67% (929) were positive. Of these patients, 62% (576) had their liver fibrosis scored, and 58% (335) had initiated treatment. Of patients with an SVR/cure test, all (274/274) were negative. Discussion: These data indicate that rural clinics can be successful providing HCV diagnosis and treatment. Pharmacists can play a key role in HCV clinical services. The outcomes of each step in the treatment process at the facility level can vary widely due to local factors. The barriers to HCV care that persist are nonclinical.

Background:The Indian Health Service (IHS), a federal agency, provides direct patient care to an estimated 1.9 million American Indian/Alaska Native patients across a large and decentralized network of health facilities. The IHS sought to implement HIV screening of adults and adolescents per national recommendations. The IHS facilities received technical support such as electronic clinical reminders (ECRs) and sample HIV-testing policies. Purpose:To determine what facility-wide policy and practices were associated with high HIV screening rates. Methods:Survey of clinical directors of 61 federal health facilities on use of ECRs, testing policies/standing orders, and other factors associated with HIV screening. These results were correlated with HIV screening performance results for each facility as derived from the IHS national database. Results:A total of 51 (84%) of 61 facilities were interviewed. In univariate analysis, factors that were correlated with higher rates of HIV screening were having an HIV screening standing order (unadjusted odds ratio [UOR] 8.7, 95% confidence interval [CI] 2.0-37.3), sexually transmitted disease (STD) screening standing order (UOR 5, CI 1.1-21.7), having an HIV ECR in place for a year or longer (UOR 10.2, CI 2.8-37.5), and inclusion of both providers and nurses in offering HIV screening (UOR 4.8, CI 1.4-16.7). In multivariate analysis, ECRs (adjusted odds ratio [AOR] 9.1, 95% CI 1.8-45.1) and STD standing orders (AOR 7.4, 95% CI 1.1-51.0) remained significantly associated with higher HIV screening. Conclusion:Policy and practice interventions such as ECRs and standing order/testing policies and delegation of screening are correlated with high HIV screening, are scalable across health networks, and will be used for improving other infectious disease screening indicators in such as STD and hepatitis C.

Background: In August 2012, the Centers for Disease Control and Prevention released recommendations to screen persons born from 1945 to 1965 for hepatitis C virus (HCV). In September 2012, Warm Springs Health and Wellness Center (WSHWC) initiated a quality improvement (QI) project to conduct HCV screening among all patients in this birth cohort. Methods: Screening rates were tracked using a nationally standardized HCV screening measure in the Indian Health Service. At the end of the project period, WSHWC staff took a brief survey to review the impact of the HCV QI Project. Results: Screening for HCV among eligible patients at WSHWC increased from 5% (47/938) in September 2012 to 76% (593/785) in September 2014. Survey data indicated that clinicians felt increased screening for HCV had a positive impact on patient communication and care. Conclusions: Primary care clinics can successfully increase HCV screening in a relatively short time period. Age based screening recommendation may provide opportunities to increase communication with others at risk for HCV. As more patients are screened, it will be important to ensure appropriate linkage to care for HCV patients.

Purpose: The Kodiak Area Native Association (KANA) provides primary health care in Kodiak, Alaska and 6 outlying villages. KANA sought to actively improve key preventive screening rates for its patients. Methods: KANA adopted an electronic health record in 2008 and deployed national clinical reminders from the Indian Health Service for 5 key preventive screenings: tobacco use, alcohol use, depression, intimate partner violence, and a comprehensive cardiovascular exam. Clinical reminders were deployed in a 5-step process: (a) establish clinical demand, (b) pilot test reminder, (c) expand reminder to all providers, (d) measure outcomes and share results, and (e) delegate clinical reminder follow-up (primarily to nurses). Results: Data from 2007-2011 show screening rates for all 5 measures improved considerably, to levels significantly above the national average for Indian Health Service facilities. Conclusions: Clinical reminders have been a key part of a multistep process to improve screening for depression, tobacco cessation, intimate partner violence, alcohol use, and cardiovascular disease. If deployed correctly, reminders are valuable tools in identifying patients who are overdue for preventive health screenings.