Commitment to Action for 7 th Generation Awareness and Education HIV/AIDS Prevention Project

1. Gender Based Violence and HIV/AIDS Risk Affecting Native Women Pamela Jumper Thurman, Ph.D. Commitment to Action for 7th Generation Awareness and Education HIV/AIDS Prevention Project (CA7AE – HAPP) Ethnic Studies Department Colorado State University

2. There are many Tribal Nations indigenous to the United States, all with unique cultural aspects…

3. FACTS: • There are over 560 federally recognized tribes. • EACH Nation has a language, ceremonies, a history, a health service system, political system, and unique socioeconomic conditions. • Many tribes have compacted to own and operate the health systems, hospitals, and clinics in their jurisdiction. • Indian Health Service is a major provider of care. • Jurisdictional factors have a great impact in tribes – State versus Tribal versus Federal. • Many tribes are Sovereign, meaning that they are a Nation within the United States – this status makes us unique among ethnicities.

5. Upon “discovery” Natives were recognized as a Nation capable of dealing with other Nations by treaty (1500’s-1828) Indian Removal and Relocation – elimination and assimilation, the long walks, the Trails of Tears (1828-1887) Reorganization and Self Government – self management transferred back to us (1887-1945) Indian Termination – violation of treaties and relocation programs, goal of assimilation (1945-1961) Self Determination – Greater empowerment of tribes (1961-now) Brief Overview of the Evolution of Tribal Status

6. Because the differing status granted by Sovereignty utilizes a Nation to Nation policy Tribes are generally equivalent to States Jurisdiction is primarily federal Health care is provided by treatied services IN PAYMENT FOR LAND TAKEN Health care budgets are very limited Cultural aspects of being Tribal/Indigenous are an important issue in the provision of appropriate treatment for Native clients/patients Why is this relevant?

7. What is Violence Against Women? • Violence includes but is not limited to: physical aggression, assault, sexual assault, emotional, intimidation, stalking, economic deprivation • Puts a focus on females as the only victims of violence

8. What is Gender Based Violence? • Gender-based violence reflects and reinforces the inequities between men and women and compromises the health, dignity, security and autonomy of its victims. • It encompasses a wide range of human rights violations.

9. Winnipeg, Canada

10. Gender Based Violence Among American Indian and Alaska Native (AI/AN) Women • One in three AI/AN women have been raped or experienced attempted rape. • The rate of sexual assault for AI/AN women is more than twice the national average. • Yet, arrests are made in only 13% of sexual assaults on AI/AN women. • Indian Health Service provides exams for women who have been raped in only 27% of their funded health facilities. • - Department of Justice

11. Barriers and Challenges • Focus groups in Alaska and remote reservations report that if there is an assault and police are called, there is seldom a response or the response is slow. • In 2011, the Justice Department did not prosecute 65% of the rape cases on Indian reservations. • AI/AN women are not pressed to report rape.

12. Violence Has Profound Impact • Emotional/psychological problems • Unwanted pregnancy • Risky abortions or abortion related injuries • Gynecological complications • Sexually transmitted infections, including HIV

13. HIV/AIDS Rates • American Indians/Alaska Natives have a 30% higher rate of AIDS as compared to non-Hispanic Whites. • American Indian/Alaska Native men have a 20% higher AIDS rate as compared to non-Hispanic White men. • American Indian/Alaska Native women have twice the AIDS rates as non-Hispanic white women. Office of Minority Health Fact Sheet - 2007

14. Did you know… …That Native women tend to be diagnosed with HIV after the infection has progressed significantly? …that Native women die quicker after being diagnosed with AIDS? …that for a variety of reasons, Native women are non compliant with HIV and AIDS medications?

15. Estimates of New HIV Infections, by Race/Ethnicity, Risk Group, and Gender for the Most Affected US Populations, 2009

16. And yet, our STI rates reflect…. • The gonorrhea rate among American Indian/Alaska Natives was 110.2 per 100,000 which was 3.6 times higher than the rate among whites. • The chlamydia rate among American Indian/Alaska Natives was 808.8 cases per 100,000 population, an increase of 11.5% from the 2007 rates.

17. How concerned should we be? …Violence isn’t adequately addressed and AI/AN women continue to be assaulted with very little protection or prosecution of perpetrators. …Reports indicate steady increases of new estimates of HIV infection for AI/AN women from 2001 to 2008. HIV/AIDS cases increased among AI/AN women, even though it decreased among other populations. …Data is not accurate for the AI/AN population. …Because AI/AN people represent only 1% of the population, our numbers are small and we are not included in most of the HIV infection surveillance charts. ….If the focus is to be on the greatest rates of infection, we are in serious trouble!

18. Women Should Hold a Special Place in AI/AN Culture A nation is not conquered until the hearts of its women are on the ground…. Then it is finished, no matter how brave its warriors or how strong their weapons.“ - Tsistsistas, Cheyenne

19. WE AS NATIVE WOMEN SHOULD NOT BE SILENCED, OVERLOOKED, OR IGNORED! We hold the future of the tribes, as Mothers, Aunties, Grandmas, Sisters, and Elders. That is a powerful responsibility….therefore, we must be visible, we must use our voices, and we must be strong!

20. www.happ.colostate.eduwww.nccr.colostate.eduWado!!(Thank you)Pamela.Thurman@Colostate.Edu

21. Disclosure InformationPamela Jumper Thurman, Ph.D.July 22nd, 2012Interntional AIDS Conference, Washington, DC Disclosure of Relevant Financial Relationships I have no financial relationships to disclose Disclosure of Off-Label and/or investigative Uses I will not discuss off label use and/or investigational use in my presentation.

23. Salamander Trust promotes sexual and reproductive health with HIV prevention, care and support, within a holistic, gender-based human rights framework. • Salamander Trust does: • Training • Research • Advocacy work • www.salamandertrust.net

24. Reduced Gender-Based Violence • (GBV HIV  GBV) • MRC South Africa RCT • Many other studies globally • WHO 2009 • AIDS Star 2011 • 120 countries • >1,000 community of practice

25. “Violence Against Women living with HIV is: ‘any act, structure or process in which power is exerted in such a way as to cause physical, sexual, psychological, financial or legal harm to women living with HIV.” Hale & Vazquez 2011

26. Community wide support for Sexual and Reproductive Rights of People with HIV • “After being found HIV-positive, my husband left me. But after attending the Stepping Stones training, my husband decided to go for HIV testing and counselling, a thing that he vehemently refused to do in the past. His results revealed that he was HIV-positive. The training helped him to rediscover himself and he apologized for leaving me. My husband and I • are now back together and happily married • again with no incidents of violence because • we are able to communicate better as a • couple and respect each other’s rights.” • EnitaJailosi, Malawi (COWHLA) steppingstonesfeedback.org

27. Institutional Violence…. in health care settings………..

29. steppingstonesfeedback.org

31. Vickie M. Mays, Ph.D., MSPH Professor of Psychology and Health Services Director, UCLA Center on Research, Education, Training and Strategic Communication on Minority Health Disparities www.MinorityHealthDisparities.org mays@ucla.edu I have no financial relationships to disclose I will not discuss off label use and/or investigational use in my presentation Challenging HIV Research Approaches In Order to Reduce Women’s Vulnerability to Gender Based Violence

32. Employ Intersectionality Framework To Prevention, Research and Treatment of GBV Mediated HIV • Framework of GBV vs VAW/IPV • Monies, Policies and Interventions are segmented • Focus on Biological and Psychological Outcomes In Context Not Just Person Based • Who Needs To Be At The Table • ASO, CBOs, NGO’s Foundations, Government • What Action Is Needed • Intersectoral Coordination (entities outside of health but in collaboration with health in order to effect health outcomes) Vickie M. Mays, Ph.D., MSPH

33. Consensus Meeting Needed For Future Directions In Order to Develop A Global Strategy To Disrupt and Reduce GBV Associated HIV • International Best Practices • Intersectoral Approaches—NHAS • SEX EDUCATION • Research on Relationship of Political Structures, Legal Sanctions, Reward Systems that extinguish GBV Vickie M. Mays, Ph.D., MSPH

34. Vulnerability • Best Approach is Measurement of Both Risk and Vulnerability • Risk • Vulnerability Vickie M. Mays, Ph.D., MSPH

35. History of Indexes of Vulnerability Throughout The World • GDP • Dow Jones Average • Consumer Price Index Vickie M. Mays, Ph.D., MSPH

36. EXAMPLE: Vulnerability Index: Prioritizing the Street Homeless Population by Mortality Risk (Boston’s HealthCare For the Homeless) 1) More than three hospitalizations or emergency room visits in a year 2) More than three emergency room visits in the previous three months 3) Aged 60 or older 4) Cirrhosis of the liver 5) End-stage renal disease 6) History of frostbite, immersion foot, or hypothermia 7) HIV+/AIDS 8) Tri-morbidity: co-occurring psychiatric, substance abuse, and chronic medical condition Vickie M. Mays, Ph.D., MSPH

37. Creating An Index of Vulnerability for GBV Associated HIV Infection in Women • Gender and status inequalities • Sexual and domestic violence • Child sexual abuse and exploitation • Drug and Alcohol use • Political instability • Displacement • War or armed conflict • Legislation that criminalizes exchange of sex for cash, survival or resources • Legislation that fails to protect or criminalizes HIV • Human rights violations • Stigma and discrimination • Depressed economy • Poverty • Limited employment and education • Migration or long commutes for employment • Substandard employment without benefits • Gender inequality in cultural traditions and social norms • Lack of neighborhood or community social capital Vickie M. Mays, Ph.D., MSPH

38. Risk Cluster vs. Risk Environment Drug/Alcohol Marketing Drug/Alcohol Use Racial Segregation Male Incarceration Casual Sex Historical and Current Racism Long term Concentrated Joblessness Social Disorganization Unstable Relationships Social Disorganization Unstable Relationships STDs STDs Poor Education Low Access to Health Care Joblessness Loss of Low-skill Jobs Mays, V.M., Maas, R.M., Ricks, J. & Cochran, S.D. (2012) Vickie M. Mays, Ph.D., MSPH

39. Biologic Outcomes Other Than HIV, STD Or Pregnancy • Distress and Physiological Processes • Allostatic Load Vickie M. Mays, Ph.D., MSPH

40. The stress response and development of allostatic load (McEwen 1998)