HIV/AIDS Prevention

Hosts Amber-Rose and Alyssa discuss the topic of HIV/AIDS with special guests Cheryl Cook, Justine Yazzie and Fannie Jackson with Navajo Infectious Diseases Control & Prevention Program under the Navajo Department of Health. In this episode, we discuss HIV/AIDS prevention methods, treatment options and resources that are available on the Navajo Nation in order to honor National Women and Girls HIV/AIDS Awareness Day that was on March 10.  

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This podcast was sponsored by the Arizona Department of Health Services through federal funding from the Health Resources & Services Administration, with support from the Navajo Native American Research Centers for Health (NARCH) Partnership between Diné College and Northern Arizona University through federal funding from the National Institute of Health’s National Institute of General Medical Sciences, award number S06GM142121. The views expressed are the sole responsibility of the program staff and do not necessarily reflect the views of the Arizona Department of Health Services or the United States Government.

Transcript

Introduction
Ya'at'eeh. Welcome to the MCH podcast, where we discuss maternal and child health topics and provide strategies for improving the health of Navajo families. Amá dóó áłchíní ats’íís baa áháyá baa yadelti (Translation, we will be talking about the health of mothers and children).

Amber-Rose Begay
I am your host Amber-Rose Begay Begay Hashk’ąąhadzohi nishli, Táchii’nii bashichiin, Tábąąhá dashichei, Naakai Dine’é dashinali. Nataani Nez denashaa. I’m originally from Shiprock, NM where I live and work at Diné College as a project coordinator of the Navajo Maternal and Child Health Project. I am a Navajo woman and mother of 2.

 Alyssa
Hi, my name is Alyssa and I'm a senior at Northern Arizona University majoring in public health. I'm working on these podcasts as a co-host and editor for my internship, and I'm excited to be raising awareness on all of the maternal and child health topics we discuss on these podcasts. If you haven't already checked out the other podcast episodes, we encourage you to listen to them. We have some great guest speakers who provide helpful information and resources.  

Amber-Rose Begay
Today we are going to talk about HIV and AIDS in women and girls. The reason we are discussing this topic is because of the National Women and Girls HIV AIDS Awareness Day, which is on March 10th.  

Alyssa 
We invite special guests Cheryl Cook Cook, Justine Yazzie, and Fannie Jackson Jackson with the Navajo Infectious Diseases Control and Prevention Program under the Navajo Department of Health. Thank you for joining us today. Can you please introduce yourself and your work with the program?  

 Cheryl Cook
Hi, my name is Cheryl Cook. I work out of Tuba city service area. My office is located in the Tuba City Regional Health Care Corporation. I am a HIV health educator for the Navajo HIV Prevention Program. [Identifies clans in Navajo]. I work for, I work in the public health field and I enjoy what I'm doing. Thank you.  

Justine Yazzie
Hello. My name is Justine Yazzie. [Identifies clans in Navajo]. I am the HIV health educator for the Shiprock service area. Our office is located right next to Northern Navajo Medical Center. Thank you for having us.

Fannie Jackson 
Good afternoon. My name is Fannie Jackson. [Identifies clans in Navajo].  

Amber-Rose Begay 
Great Ahe'hee. It's nice to have you all join us and have you part of our series on maternal and child health. So let's get to the first question. What are the HIV prevention and treatment options available on the Navajo Nation?  

Cheryl Cook 
Well, HIV prevention and treatment options available on Navajo Nation. We all know that the most of our population’s treatment services or any kind of medical services is through the IHS or Indian Health Service and then 638 facilities. So, those are the prevention and treatment options or facilities that are available on Navajo Nation. 

We do have a main office for HIV clinic, which is located in Gallup, New Mexico, and that's Gallup Indian Medical Center. There are other facilities around the nation that people can get treatment for HIV. You know, there's facilities in Shiprock, Northern Navajo Medical Center, this like Kayenta Health Center. 

I'm going to name like the different areas. We have Tinley Comprehensive Health Center. In more rural areas, there's like Inscription Health centers, Pinion Health Center, Valley Health Center. There's the Tuba City Regional Health Care Corporation, Winslow Indian Health. And then when we talk about border towns, well, let's not forget the Hotel Medical Center where one of our HIV health educators is located. Let's not forget our border towns, including that includes county health offices, county health offices like First Nations, community health stores. They're located in like Farmington, Zuni, and Gallup. They offer, you know, HIV rapid testing; and then the main IHS facility, they offer the treatment for HIV if somebody has tested positive. 

In the Flagstaff areas like North Country Health Care, they're located in Grand Canyon, Flagstaff and in Gallup, McKinley County public health offices. There's there's there is a number of offices off the reservation and border towns and then within our reservation. So on all eight service areas, they do have Indian health services, 638 facilities available for people that, that want to have or do want to get an HIV test, or hepatitis blood testing done. These facilities, they offer contraceptives like for women and then they, they offer condoms in the pharmacies, which, you know, even in the women's clinic, same day clinic. We try of I guess the hospital that I work with, they try to provide it in all the clinics. And I believe, I believe all the facilities do try to do that, in all, you know, having condoms available, readily available for people to take. They also include Prep and PAP, which is the HIV prevention method that they use; which is, you know, medication that helps to prevent HIV. And I think we're going to be talking about that later in the podcast. And then also as well as counseling, counseling for people who want to learn more about STIs, HIV AIDS, and the prep pap contraceptives, you know. Condom usage because there's a number of different condoms out there and other treatment options. And you know, something that includes with HIV, we do have injection drug users that use that use, and, you know, there's people out there, there's a number there's a percentage of people out there that do that use injection drugs. In which could, you know, which which is probably well, which is where they could contract HIV; not probably, but could.

But so I wanted to mention syringe exchange services in those areas. Some border towns do have it. I just want to mention Gallup and Farmington. I know New Mexico, Department of Health, you know, or New Mexico side. They do have syringe services. However, on the Arizona side, I can speak for the Arizona side because I'm on the, the Western agency side as well as the other ladies that work with me. Arizona right now does not have syringe exchange services right now. Right now, it's against the law to have. to have, you know, syringe paraphernalia and exchanging that out of syringe exchange store or wherever they may get clinic. So so those things are out of the question for Arizona right now. As for Navajo Nation, when we talk about syringe exchange services, Navajo Nation does not have any at the moment. However, we also have Navajo Nation HIV prevention program, who is, who we work for. We provide prevention, education on HIV, AIDS, STIs, condom usage, and we also distribute condoms. You know, we distribute condoms to a number of like, for instance, gas stations, you know, places of businesses that will accept them and give them out for free. Wherever we can provide them and we can collaborate with these other, these businesses, we'd like to provide them free to people out there. We also provide confidential HIV rapid testing and counseling as well. With that, the results or the results can be available in less than 30 minutes. But right now, pre-pandemic, these are the services we used to provide. But right now we're kind of on a, on a hold right now for face-to-face contact. 

We also provide with the HIV rapid test. First of all, it's a simple, small sample of blood or saliva that's taken to test for HIV antibodies. And that's, that's the test that we have. And the tests are usually we can provide in the test, we can be read within 20 minutes. It takes just about 30 minutes for us to get the entire, the entire service done with a client that we are working with. So, but the thing about that, we were counseling, we asked, you know, we usually talk about continuing even after the test, but they continue to protect themselves, to stay negative. That includes protecting themselves during sexual contact for sexual having sex that includes wearing condoms are using condoms. And then that includes even using prevention methods like PREP medication, PEP medication, protecting themselves. If you inject drugs, you know, preventing mother-to-child transmission as well. Getting those prenatal visits in and making sure that, you know, they're tested and they talk to a provider when they first get their prenatal exam. And I believe they also test for other STIs as well. And then protecting others from getting HIV, you know, if they test positive, we want to make sure that they are protecting their partners or other people and that they're making sure that they're aware that they do, that they are positive. But those are things or those are some prevention things that we go over with them prevention, education. 

It is important to get retested after having risky behavior or after risky behavior. You know, if it's not wearing a condom or if they have multiple partners, you know, they're injection drug users. There's and we'll talk about that later in the podcast because those risky behaviors can have, you know, if they were exposed to HIV, it can take up to three months for a new infection to make the test positive. So but overall, the CDC recommends everyone 18 years and older to get tested at least once in their lifetime. 

So other services that are available, of course, we talked about treatment and prevention options. They have options like Prep and PAP. The Navajo Nation Health Education Program. We do educate about PREPand PAP and recommending safer sex and prep education to people or to persons at risk. So that's the type of education we offer. But in order to get PREP, they have to go see a provider at one of these IHS Indian Health Services or 638 facilities. Other things that we how we educate is through social media as well. We use Facebook and we use Instagram. We do post prevention education messages on those platforms. We also, we used to use Grindr, and I don't know if anybody is familiar with that. It's a dating app. And what we did was we used the we used pop-up ads for prevention education. That was a way for us to reach out to the youth and young community and especially men having sex with other men. That was another, that was another great tool that we use for education as well. Now that we're in the virtual, you know, right now we're doing a lot of virtual events and presentations since COVID. We also use another text app. It's called We Are DNA. So you would text 9-7-7-7-9, you would text that number, and usually, the person would get like one time per week. Like every weekend they would receive like a text message, a prevention message about safe sex, maybe, you know, some kind of public health message. So those are ways some ways that we use, we utilize or, you know, our prevention education for our program. 

Other programs that offer the prevention, just the prevention side, not treatment, but Navajo Nation CHR programs and then the social hygiene program. They offer a contact investigation and then they offer a partner notification. Contact investigation and partner services for Navajo people and the residents of Navajo, like who have tested positive. So most of the time when they are, they work and collaborate and partner with our program. Our program provides the education component, and then they are the contact investigators. In other words, they go out there and they find the patient that's positive, whether it be syphilis, whether it be chlamydia, gonorrhea, HIV, and they get them to come in. They do partner notification. What they do is, they find out the names of their partners or how many partners they've had, and then contact them as well. And that part we leave up to their program. And then they also collaborate with AHS (14;57) as well, county or state health departments for the off-reservation cases. So there are some cases that will be like in the border towns like Gallup or Farmington or Flagstaff or Paige. So they do work with those county health or state health departments; they do work with Arizona's Department of Health. And, and they can find out a lot of, I guess, where they've been treated previously. Have they been, have they tested positive before for the STI? So they do things like that. So we work in conjunction with their programs.  

Alyssa
Thank you for that. So what is HIV and AIDS and how does it impact women and girls on the Navajo Nation?  

Cheryl Cook
HIV AIDS, HIV, it stands for Human Immunodeficiency Virus. It's a viral infection. Whoever may be engaging in sex, whether, you know, it's usually risky behaviors that leads to it and, you know, leads to them getting the virus. But it does stand for human immunodeficiency virus. AIDS stands for auto immunodeficiency syndrome. 

So there are two different, there are two different, kind of, like they they go hand in hand. But one is kind of like in the beginning stage, which is HIV. That's how I like to explain it. And then AIDS is kind of like the end stage. So when a person is HIV positive, they do how they can get medical treatment while having HIV, even, you know, they can live a longer and healthier life. But however, if a person does not get tested annually and they engage in these risky behaviors, they can, they can end up having AIDS. AIDS as defined by providers when it when a patient has, you know, a CD4 count or white blood cell count below 200. And I think that's something I did not mention; HIV does. When HIV enters the body, it actually attacks a person's CD4 cells. Or, in other words, I like to say white blood cells. And what those cells do for our body is protect us from, you know, foreign substances, maybe virus, bacterial infections. And those are very important to us, for our bodies. So HIV does attack those important, important cells. And those are cells that we need to keep our body healthy. Without those cells and without treatment, a person doesn't get treatment over, you know, some years or in a certain amount or course of time, they can end up with AIDS and AIDS, then I guess you could say diagnosed when their CD4 count is below 200. Once they're an AIDS patient, there's no you know, even if they get their CD4 cell count or white blood cell count above 200, they're always considered or always going to be known as an AIDS patients. So that's the difference between HIV and AIDS. 

But HIV AIDS since 1987, our first case here on Navajo Nation. Since then, 637 people with HIV, there has been 637 cases with HIV AIDS on Navajo Nation. And this is coming from the Navajo area, IHS 2018 report. So and this is the 630. This includes 638 health facilities. And this includes the data from Indian Health Service. Those are known cases that have been treated. So during 2018, there was, the latest report had said that there was 58 new people living with HIV AIDS on Navajo. So there was 58 new cases for a calculated like HIV AIDS incidence rate of 24 people per 100,000. So that's 24 people contracting HIV every 100,000 people, if that's, if you can understand the. So this was the highest number and highest incidence rate or the highest rate of new cases in the past five years. During that time, and at the end of that year 2018, there was 509 persons that were living with HIV AIDS on Navajo Nation. So of those 58 cases, when we talk about women, 14% were female. And the average age for women during that time was 30 years old. So 75% of those new infections, so that 14% equaled eight new females. So of the eight females, six were from the age 25 to 34 years old. What we found that, in prior years is that women were older, like they were like 48, 48 years old; that was the average age. So you can see over time, you know, as time went on, the age range has, has lowered. So you see more females of age 25 to 34 now. 

But when we speak about women too as well being impacted, I like to also include like not only are we being impacted on Navajo Nation, I think, globally, we're impacted. You know, women are definitely underrepresented in HIV. There's not enough research on women, you know, you know for HIV. It seems like from the articles and research that I've done, it seems like they focus more on the men that have HIV, and that's where women are underrepresented. So a lot of times I think that more women do have HIV but are not, are not represented in this in this area. Right now, they're focused more on men who have sex with other men. And this includes women who are in domestic violence relationships, you know, who are being victimized. That impacts women at higher rates as well, and especially women of color. Women of color, including our population. When we talk about domestic violence and victimization. We're thinking, I'm thinking a lot of women, if they're in a domestic violent relationship sometimes, are, you know, they have no choice; they have no choice in the face of having engaging in sex. Sometimes they're made to have you know, sometimes they're being raped. So a lot of times they don't they're not using condoms. You know, they're being forcibly, they're being forced to have sex, and then they're being victimized. So I would think that those are ways that, you know, this is impacting HIV, that is impacting women as well.  

Justine Yazzie
The female across the reservation, a lot of I guess we're going to talk about it, but, about a lot of taboos and a lot of things. Parents are not teaching their young girls about the safety or the protection or the prevention of what HIV is. Sexual health is also still a taboo across the reservation. A lot of homes do not talk about what sex is. I think we still live in that society when the word of sex gets brought up, a lot of parents tell us that you're not supposed to talk about it. So I think that also impacts women and girls on the reservation.  

 Amber-Rose Begay
Okay. Thank you, Cheryl and Fannie Jackson. We really appreciate your insight on these questions. And so the next question is, what are the most common risk factors of HIV on the Navajo Nation?  

Justine Yazzie
So the most common risk factors, or one that Cheryl mentioned, is MSM, which is men who have sex with men. This continues to be a really high risk factor for HIV infection on the Navajo Nation. And that latest Navajo area IHS annual report, MSM did account for over half of all new HIV cases. Another is heterosexual sex; they accounted for 31% of those new HIV cases. And also 63% of people who did report the heterosexual sex as their primary risk of HIV infection were from women. Other risk factors can include like having a history of STIs, getting contracting STIs, being unaware of their HIV status; a lot of people don't know, you know, their status of alcohol and drug use. This is also a really big issue on the Navajo Nation, as you know, being under the influence, it can alter people's judgment and it does lead to them, you know, participating in sexual risky behaviors like not wearing a condom almost. But also, it increases with, you know, the MSM who do drugs and then heterosexual couples who also do drugs. Having multiple partners too increases your risk. And you know, what you're mentioning earlier too, is that intimate partner violence forcing intercourse with an infected person or with a partner who doesn't know their status, and also the increased sexual risk behavior of not wearing a condom. So those are the most common risk of HIV on the Navajo Nation.  

Alyssa
Thank you, Justine. What is the most common way HIV is transmitted and more specifically, among women and girls?  

Justine Yazzie
So the most common ways HIV is transmitted is through anal or vaginal sex without a condom, and also sharing needles, syringes, or, you know, other drug injection equipment. There's also another chance of transmission which can occur during pregnancy when they deliver or through the breastmilk. But for women and girls, the most common way of contracting HIV is having that unprotected sex with a male partner who might be HIV positive or someone that they don't know what their HIV status is. Women also have a greater risk of contracting HIV, more than men, because the vaginal tissue for women is more fragile and can tear more during sex.  

 Amber-Rose Begay
Thank you, Justine. The next question is prophylactic treatment on Navajo Nation widely accepted? Or are there any stigmas?  

 Cheryl Cook
So prophylactic treatment, these treatments, well, it's also known as prep and prep pre-exposure prophylactic. That's what, that's what PrEP stands for. And then PEP stands for post-exposure prophylaxis. So PrEP is a medication taken to prevent getting HIV. Right. And it's highly, highly effective, effective like when, when it's taken as prescribed, and this is to reduce a person from getting HIV. It's also, or HIV from sex. And they say, well, you know, CDC says that 99% of the time it does, it is, that's how effective it is. And injection drug use is also effective against injection drug use. As we know, IDU user we like to call them, injection drug users are, you know, affected by HIV because they're sharing needles and syringes and drug equipment. That's another area of concern. And it decreases that by at least 74%. Condom use is still important, though, although it's still important while using PrEP because PrEP only protects a person from HIV, not any other STIs, and that would include the other common STIs like syphilis, gonorrhea, chlamydia, you know, what have we. So that's what PrEP is used for in PrEP is for anyone that is high risk. Anyone that has, you know, high risk that we mentioned multiple partners, not using condoms, if a partner that is HIV positive and then another partner is negative, it does provide that type of protection against HIV, but it's not always well, you know, but it's not 100%, but at least 99%. So with PrEP, you always have to use a condom. 

But with PEP, PEP is post-exposure prophylactic. And what, with PEP is it,  it is a medication taken to prevent HIV as well in an HIV negative person, you know, who has had high risk exposure to HIV. Usually, that's you know, this exposure usually is through a medical emergency. Let's say someone was forced to have sex without a condom; in other words, you know, sexually assaulted. Also, it's mainly I think that's what it's used for that because a person that's been exposed to somebody or if they were, if they were forced to have sex with someone and they were exposed to HIV. The thing with PEP is they have to get in for treatment or they have to go to the emergency room or they go to their nearest clinic within 72 hours. Every hour that, you know, goes by is precious. Time is, time that they is, time that they need to get there as fast as they can to eliminate HIV if they were exposed to it or if they knowingly were exposed to it, getting there within 72 hours, taking the pill. After that, they are given a prescription for it. And usually, well, normally the person would take it for once a day for 28 days. That's what happens. 

But the treatment for on Navajo Nation. Is it widely accepted? I don't have an answer for that. But right now a lot of people do have do, do know about you know, we are trying to get that education out there for PrEP and PEP through our program services. I do believe that a lot of people are aware of it. I mean, if they have been into an annual exam, they're always, you know, usually the provider will go over something with them if they are at high risk for getting HIV or for contracting HIV. So they are always given that option. 

I just want to mention the 2011 Navajo Nation HIV AIDS Act recognizes when we talk about, you know, stigmas around PrEP and PEP, the HIV Act does recognize stigma and discrimination, social stigma associated with HIV infection. And then Navajo Nation supports the efforts in, you know, eliminating, eliminating stigma and creating a social environment like a positive social environment that allows people living with HIV to fully live their lives without the additional burden of stigma. Stigma is always going to be there. You know, it seems like, you know, from my experience, I see it out there and, you know, I know personally when I talk to, you know, my regulars that come in for HIV rapid testing to the office, they always like to come in for the rapid testing. And then if they're frequently, like frequent fliers, people that come in all the time for a test, I always educate and say, hey, you know what would be a good option here? You know, you come in here and you're always worried that you might have been exposed to HIV because you didn't wear a condom. So I think that you're a good candidate. Maybe I would pass the information on to that patient for PrEP, you might want to talk to a provider about, you know, getting this PrEP for PrEP medication for yourself. So that's how our program, you know, helps support the patient or client when it comes to PrEP treatment. You know, some people are very accepting of it and they're willing to go and get there, you know, go see a provider. And then after that, they'll see a pharmacist about possibly getting them on PrEP or PEP or not PEP but PrEP mainly. The Navajo Nation and regulations on Navajo Nation, they want to ensure people living with HIV and those that are at risk are protected from discrimination when it comes to stigma and stigma against treatment like this.  

 Justine Yazzie
I think across the reservation we deal with a lot with stigma all the way from the individual's family. A lot of times our client, our clientele say that they don't want to on PrEP 32:32 because they don't want their family to find their medication. So it starts within the home. And so a lot of times that's the reason why our clientele don't want to get on PrEP. They don't want to show their medication. So a lot of time, that's what we deal with. And then even then, there if we do have a health booth out there and we have a bowl of condoms that we advertise as free condoms, a lot of our clientele are hesitant to come and pick it up because they're afraid that somebody is going to judge them. If it's a big event they're afraid that somebody is going to recognize them. So a stigma is we're still dealing with it every day. It's a daily thing. Our people are still not accepting what HIV and AIDS are. So stigma is still really high across the reservation.  

 Cheryl Cook
Excuse me. Hi, this is Cheryl again. Like Dani said, I think, well, there's a lack of education in that area and a lack of understanding of HIV AIDS. You know, a lot of people have a missed understanding about HIV, how it's, how it's spread. I think a lot of people don't know these things that HIV is not spread through, you know, mosquitos, ticks, saliva, kissing, you know, sweat, using the same towels, using the same restrooms, toilets, showers, whatever it may be. It's not, it's not passed by hugging or shaking hands, you know, or sitting with the same person at a table, eating with them or even through utensils or using the same cups or, or anything like that. But, or even through water fountains or doorknobs, you know. I think people have a misunderstanding about that. And the 2011, what I have mentioned, 2011 Navajo Nation HIV AIDS Act does recognize that to stigma being high and remaining high for, for the Navajo people, or for our people, so. I just wanted to mention that as well.  

 Alyssa
Thank you for that insight. So now you mentioned education and how you wanted to try to increase that within the Nation. So are there any barriers to access. to accessing HIV and AIDS education and testing services?  

 Justine Yazzie
Just like I think all these questions do intertwine. So, barriers, we see it, we deal with it like on a daily. So there are barriers to accessing HIV/AIDS, education, even the testing and screening service on the reservation, transportation. One of the big things that we see among our clientele is transportation. A lot of our clients don't have a reliable transportation to get to the hospital, to get to a place where they can get screening or to pick up their medicine. So we see that, that's one of the main problem is transportation. And then when the when they get to the confidential screening, a lot of them are afraid that they will run into a family member who works at the hospital. There's going to be no confidentiality. Insurance is another thing. I know across the reservation our 638 facilities. They do provide that free testing. But a lot of times, if they don't want to go with us to our IHS, our 638 facility, they choose to go to a private entity. Insurance can become a barrier and then even the education part. And then, then with the COVID 19. The pandemic has put a barrier on a lot of our teaching and our HIV service, our testing sites right now, we're not doing, we're not providing no testing to our public. So the pandemic has kind of put a barrier there. Alcohol. I think a lot of our, our people use and abuse, substance abuse, alcohol, and other drugs. So that becomes a barrier. And then a lot of times when they're in that state of mind, when they don't practice a lot of their prevention skills or their like condom usage that they don't remember or they forgot how to use it or they don't use it right, so that becomes a barrier. So all of that is and then even our mental illness, a lot of our clientele are going through a lot, they're being challenged on a daily basis. So those are all barriers to HIV education and then the testing service.  

 Cheryl Cook
This is Cheryl, I just wanted to comment again on the alcohol usage, just from experience speaking from experience, yes, I do watch our you know, our public health nurses here where in my area, you know, the STI techs that we have from social hygiene program. They do the partner notifications and contact investigations or contact tracing. Alcohol seems to be a big crucial barrier because for HIV care or even STD care, like syphilis, it's kind of and it's not kind of, but it is a big increase now, right now on the reservation. And alcohol is usually, you know, how that plays a role in being a barrier for patients, is like when I hear public health nurses, when we were having our monthly meetings, I hear them saying, you know, our clients sometimes move around a lot when they're drinking and they're usually not home. So they're always sometimes they're out on the street, you know, and it's really hard to contact them and get them to come in to get that treatment or to get the if it's syphilis, to get their penicillin shot or, you know, for their treatment. And especially like for syphilis, they need three if they're in the late stage of syphilis, which is like the late, late stage, they need three shoot and that comes in weekly or one-week intervals. So things like that. And especially with HIV treatment too. I mean, a lot of them, their adherence to medication will decrease because they're not doing, you know, maybe like Frannie said, they forget to take their medication on the Daily.  

 Amber-Rose Begay
Thank you. So you talked about confidentiality, insurance, transportation, how COVID 19 is a barrier in getting the education and providing testing resources to the communities as barriers to accessing HIV AIDS prevention services. So and then also, Cheryl you talked a little bit about how, you know, adherence is important when it comes to treatment. So when people maybe when you go out, maybe before COVID or when you would go out to provide like education at community events, how willing were they to get tested and then if needed, treated?  

 Justine Yazzie
So we started our HIV prevention program, we started it back in 2010. We started at the Navajo Nation Fair. We did a kickoff and we did a rapid test. So we during that time, we were actually persuading our clientele to come in to get tested. Back then, we're using incentives like really nice lunch bags, and that's how our people were getting tested. So this was new back then. There was a lot of programs that were doing rapid testing. So when we started then that's how we were persuading our clientele to get tested and then comparing that to now before COVID, we were actually getting our clients in on a voluntary basis. I think that trust was built among our quintile. So we were getting phone calls. We were, we had open door and here at my office a client can actually come in, just sign in and say, Hey, I want to test. So at, in 2018, our clients were coming in voluntary. There was no incentive to be bribed or to be offered. So it seemed like we built that trust. As long as the HIV prevention program has been around, and I think our program has built that trust. So before COVID, our clientele increase a lot of our clientele, just like Cheryl's named, they're frequent fliers, people who still practice risky behaviors, or maybe because maybe because of alcohol, they didn't use the condom. So they'll come in and then they'll get tested. So there was a big change from 2010 to 2018. So a lot more people, I think, just building that trust with our clientele, more people were willing to come in. But on the other hand, people that were aware of our program and we still had to kind of educate them. And then when you do the education and you kind of mentioned the risk factors, that's when clientele says, okay, do you think I should be tested? So certain people, we still run into some people like that. And I think that after increasing the education, after talking with them, I think they get that interest in getting tested.  

 Alyssa
Thank you for that, Frannie. I like that you talked about building trust and how important that is because people will be, feel safer coming in to get tested. So, what steps would you recommend to someone who tested positive for HIV?  

 Cheryl Cook
Speaking to the audience, like if you know you have or if they know a person knows that they have engaged in risky behavior, which we spoke about earlier, you know, please get tested at your local health care facility. You should be getting tested at least once a year, even if you're not sexually active. I think it's still recommended that people should get tested once a year. Should their results come back positive, their health care provider should be able to link them to receive care and treatment. And what they would have to do is follow their doctor's recommendations and treatment guidelines to help, help them achieve what we call you as you, which is no nationally undetectable equals and transmittable. So if they're taking their HIV AIDS medication regularly, then they would become undetectable and that would equal untransmittable. But most importantly, they would have to refrain from using alcohol and drugs. Of course, living with HIV AIDS for a very long time is manageable and is possible and possible. 

Also, as well as you know, when our program provides rapid tests out in the field and the patient tests positive, we link them to care with a referral. Every service area that we, that we provide, you know, provide our services, if we have a patient that tests positive with the rapid test and of course we link them to care with the referral and we follow up to make sure they, they, they were linked up to maybe a PHN 44:17 and or a provider. We make sure we make that contact for them. And even when we use to test in correctional facilities, I would have a few positives there. Pre-pandemic, we used to provide services and correctional facilities like we would team up with like for instance, my area, North Country health care, and we would provide hep C testing and HIV rapid testing together. We would definitely link them up to care and make sure we follow up. 

They will they would follow up, if they do follow up, they will have to follow up at a local IHS or Indian health facility or 638 facilities for further testing and confirmation. The patient, when they go in for their confirmation, they should expect a blood draw at their first visit. Then normally a follow-up appointment will be made and they will be seen like 1 to 2 weeks later to discuss the new lab results with their doctor, whoever their provider is. While waiting for the confirmation they also need to practice abstinence, which is not having virginal anal oral sex and don't share needles or other drug equipment, if that's what they're doing. If they do have sex, their partner should be aware that their initial test was positive. They should still be making that contact to their partner and letting their partner know that they are positive and they should still use a condom with all, with all their sexual contacts or sexual interactions with other people.  

 Justine Yazzie
Hi, this is Justine, something else to add on about this question is for those who get recently diagnosed because of that diagnosis, they do have HIV. It can take some time to process that news, many people have many emotions. They'll have that anger, hopelessness, sadness, so, you know, also, disclosing it to someone you can trust can help process those thoughts and emotions. And like Cheryl mentioned it's really important to share that information with current and past sexual partners.  

 Amber-Rose Begay
Thank you, Justine. Yeah, so thanks for sharing like what the next step would be for somebody who might be HIV positive or who tests positive for HIV, should I say? And you know, that can be scary. I, I've got tested for HIV many times in the past, and it's always scary to go in and, you know, say, I want to get tested for any STI, but even HIV and also waiting for the results. So thank you for sharing. I mean, support is very important and I think that's a good point that you made there, Justine. 

The next question, what other HIV prevention and education resources are available on the Navajo Nation?  

 Justine Yazzie
So just kind of repeating, you know, again, we have our HIV prevention programs. We'll do our virtual HIV AIDS prevention, education, our condom distribution, and the confidential HIV rapid testing and counseling when we're able to. Our health education program, BHR 47:28 program, they're social hygiene technicians. And, you know, our in-person services, again, are restricted due to COVID, but of course, those IHS and 638 facilities still offer those HIV prevention and education. Some programs like health promotion, disease prevention. They also do that education. Of nomination nearby border towns, you also have your local county health offices, who also do the education and prevention testing services. And then some online services I want to mention, you know, some outside programs that cater to American Indian communities. They offer online services, you know, like with HIV testing kits or ordering condoms. And then you can also check out the CDC and other health websites, you know, locate some services or learn more about HIV.  

 Alyssa
Thank you for that, Justine. Are there any cultural teachings around HIV and AIDS?  

 Justine Yazzie
So cultural teaching around HIV and AIDS. I think that starts within the home. A lot of times when we do our teachings, mom and dad has to play a big role relative to aunts, uncles, grandparents. I think they have to play a big role when it comes to traditional teaching. There's not really no teaching on HIV and AIDS, but I think we come in from the self-respect at this [Navajo 48:55]. How to, how to do self spirit is the most important thing, and taking care of oneself, and then their overall health.

I do when they, when a girl reaches [Navajo49:05] their puberty ceremony. During that ceremony, they teach about, a lot of mentors, the individual, the one lady who is take as a mentor or the girls, aunts, uncles, aunties and grandparents or grandmas their [Navajo 49:25]. They're the one who does a lot of teaching and they mold the, they're in the four day ceremony, and they mold the girl, and they do a lot they offer a lot of teaching. So we do education though, that's one of the things I bring up, especially to our high school student. You know, they're near puberty ceremony, self respect. [Navajo 49:45], you know, that comes from there. When those are taught at that young age individual, and since that we're talking about females, female will respect themselves. And so when it comes to deciding to have sex or if they should be pressured into having sex, if those are taught at an early age, I think they can learn how to negotiate. They'll know how to take care of themselves when that, those things comes up, especially with sex. So education cultural teaching is done there, it kind of molds them out to be young, respectable ladies. So I think [Navajo 50:23] Those are taught. 

And even for the guys, there in a, there in [Navajo 50:27]when their touchy voice is changing. You know, when my son became of age, that's one thing that I ask about: who does that teaching? So my husband kind of took that role. He does a lot of teaching during the sweat lodge ceremony or even when they're just outside talking. So they have their own little spill on education. And one of the things I asked was what is being taught in there? What does the [the audio cuts out] young men get taught? So a lot of it is self-respect. [Navajo 50:58] is also taught there, self-image, self esteem, all is taught. Even on how STIs is passed and how you can encounter those things if you make bad choices. Those are things that you can come upon. So teaching the traditional teaching is there, and parenting has a lot to do with it. I think mom and dad are the first teachers and they should be teaching about these. 

So when we do education go, when I do education, I always like, especially to young girls, young boys, I always tell them that you need to be respectful to the opposite sex. That comes with our traditional teaching. You should respect one's body. You shouldn't, you should ask before you do something. So all of that traditional teaching is a big thing when it comes to sexual health. I think that it should be taught in all homes, so both female and male. The [Navajo, 52:01] self respect has a big role when it comes to teaching sexual contact, sexual teaching, even when it comes to STDs, STI, HIV, AIDS. An individual has strong traditional teaching, I think that they can better overcome and better make a better decision when it comes to sexual, sexual encounters. So it is taught, it should be taught too. 

I attended a webinar on one of the traditional practitioner from VHS 52:33, and so this medicine man says that he was talking about our teachers from way our ancestors are teaching, our grandma and grandpa is teaching. So he says that us, we should be using the words I love you really on, really early on in our relationship because I love you should be, it should be said or it should be uttered until you can financially, emotionally, mentally, and stable provide that to your partner. And so I, that was really interesting. And he says that now today we use those words just freely, like up to a month into our relationship. And he kind of mentioned that when it comes to sexuality, social teaching, STDs and STI, you kind of mentioned those in those teaching. And I was telling Cheryl about that, and I kind of posted something like that on our, on my Facebook page. And I got a lot of disagreement from the public. And it was interesting to see a lot of those. So that traditional teaching sexuality is in our teaching, our grandparents and our [Navajo 53:44 & :46, our knowledge teachings. So if you are taught that book, that's one of the plus things.  

 Amber-Rose Begay
Yeah, I think, you know, our young people to even our adults, you know, there's a lot of responsibility when it comes to, you know, growing up. You know, we have, we find out that there's a responsibility to take care of our own selves. You know, mom and dad can make your dental appointments for you anymore, you know, insurance and then school and then career and then relationships. It's a lot of responsibility. And so thank you for sharing that. And I just want to thank you all for joining us today. We really appreciate your time and all the valuable information you provided. And I would like to encourage our listeners to get tested for HIV or other STIs if you are sexually active. Also, talk to your partners about their HIV status. Ask them, have they been tested for HIV? Try to normalize that conversation in your relationships cause it, because it is very important to take care of yourself and also those around you. Ahe'hee. Thank you.  

Cheryl Cook
Ahe'hee. Thank you, Amber.  

Alyssa
Thank you, everyone. I really love listening to all of the insight.  

Outro
Ahe’hee. Thanks for listening to the MCH Podcast. For more information about the Navajo MCH project, please visit us on Facebook at the Navajo Maternal and Child Health Project at Diné College.