In this study, we interviewed and obtained clinical chart data from 36 HIV-positive Navajos receiving HIV care through the NAIHS. To identify factors associated with HIV disease progression, we looked for associations among sociodemographic, economic, and medical characteristics with VLs and CD4 counts. We found important differences with incarceration in the last 12 months, household incomes of <$1,000/month, alcohol abuse, and use of traditional medicine. Most importantly, when VL was assessed with a history of incarceration in the last 12 months and alcohol abuse, alcohol abuse remained the important indicator of poor outcomes.
Incarceration and abuse of alcohol were interrelated. Incarceration among the AI population served in the 4CC project was often linked to alcohol-related offenses, especially driving while intoxicated (DWI) charges. A study of AIs in the northwestern U.S. showed that AIs were overrepresented among individuals arrested for DWI by a factor of 2.5, compared with the overall DWI arrest population.18
Our data suggest that alcohol abuse underlies the statistical significance in VL and CD4 counts, more so than the apparent effect of incarceration.
Another possible factor is lack of access to appropriate HIV medical care and medication while incarcerated. A study conducted in British Columbia, Canada, showed that incarceration in the last six months was connected to a risk of failure to suppress HIV RNA levels in HIV-positive patients on HAART.19
Furthermore, incarceration was associated with increased risk of HIV seropositivity for everyone, regardless of race and gender. HIV/AIDS prevalence in inmate populations is estimated to be four times that in the general population.20
Less conservative estimates place the prevalence among incarcerated populations at five to 10 times that in general populations.20–22
Consistent with the study cited previously, our data showed poor CD4 and VL outcomes for AIs who were incarcerated in the last 12 months. Treatment interruptions during incarceration and post-incarceration living conditions may explain these findings.
Low household incomes may restrict access to health insurance and transportation to care. Although the IHS provides care regardless of income or private and government insurance status, patients seeking care in the HIV clinic in Gallup, New Mexico, have to travel a mean of 90 miles roundtrip to see an HIV specialist, with exceptional cases of 360 miles of roundtrip travel. Lower-income patients might find the cost of gasoline prohibitively expensive and have poorer access to the free health care to which they are entitled.
The most intriguing finding of this study was that use of traditional AI medicine was associated with lower CD4 counts. This effect was unanticipated and surprising to the investigators. Traditional Navajo medicine has as its goal restoring “hozho,” or balance, for the sick person. The sick patient will usually first seek the care of a diagnostician who uses various means, including crystal-gazing, star-gazing, or hand-trembling procedures, to determine the cause of illness. Illness is usually attributed to breaking of taboos/rituals (e.g., contact with snakes and lightning), contact with ghosts, or witchcraft. To restore hozho, the patient is referred by the diagnostician to a Navajo medicine person who performs the appropriate therapeutic ceremony. These ceremonies generally entail prayers, chanting, sand-painting, and therapeutic herbal medications.
There are several possible explanations for this finding between traditional medicine and CD4 counts. One possible explanation, perhaps most obvious to practitioners in the Western medicine scientific model, is a potential drug-drug interaction between traditional herbal medications and ARV therapy. Drug-drug interactions between herbal medicines such as St. John's Wort and the protease inhibitors are well described in the medical literature.23
The rich pharmacopoeia of Navajo traditional medicine has never been studied by Western medicine practitioners, and the possibility of drug-drug interactions has not yet been investigated. However, there have been studies on indigenous medicines used to treat HIV in South Africa that suggest avenues for future research.24
Another possibility is that individuals attending traditional healing ceremonies have suboptimal drug therapy adherence for the duration of the ceremony, though small sample sizes precluded a deeper investigation of this relationship. It is customary for Navajo patients undergoing traditional healing ceremonies to abstain from contact with things foreign, including non-Navajo health-care providers and non-Navajo medicines and procedures. Ceremonies can last as long as five nights and are often followed by other lengthy ceremonies to cure a single illness. The importance of this effect would be very difficult to quantify.
An alternate explanation for the negative correlation between traditional healing and CD4 counts is a historical and cultural one. The Navajo have an ancient traditional medicine system that has served them well for centuries. Contact with Western medical practitioners has only taken place for the last 140 years, and Western medical practitioners and educators on Navajo lands historically attempted to supplant traditional healing, leading to parallel and comparable, rather than integrated, systems.25–28
The NAIHS itself was not established until the mid-1950s. Many Navajos continue to adhere to traditional cultural beliefs and practices, and have much greater faith in the care provided by a medicine man than care provided by Western practitioners. As one Navajo coworker told one of the authors, “Doctor, we Navajos only come to see you IHS doctors as a last resort.” The two systems represent very different world views. Influenced by the historic separation of Western medicine from traditional treatment, the patients in our study who sought traditional treatment may have had lower CD4 counts because they sought Western medical care only after exhausting all possibilities in Navajo traditional treatment. This suggests that Western and traditional health-care providers have to work together to support HIV/AIDS care for their clients.
This study had several limitations. First, there was a time lag of slightly more than one year between the final patient interview and the last determination of CD4 count and HIV VL for 15 of the study participants. This could have led to bias in favor of improved CD4 counts and HIV VLs, due to changes in the demographic and socioeconomic study variables. Second, although some participants had longitudinal data, most did not; therefore, we were unable to account for changes in the independent variables over the course of treatment. Third, the physician-/pharmacist-determined adherence measure was an indirect estimate. However, contrary to studies where physician-reported adherence was not correlated with VL,29
we found a significant association. In this study, the triangulation technique of including open-ended items, closed-ended items, and pharmacy records strengthens our physician-reported adherence measure. Finally, as this study was a cross-sectional design, we can only evaluate possible associations and, therefore, cannot state any causal relationship.