For fiscal year 2007, IHS projected a user population of about 1.5 million individuals, or about 35 percent of the population who identified themselves as American Indian or Alaska Native in the 2000 U.S. Census. Not all persons self-identifying as American Indians and Alaska Natives in the U.S. Census are members of federally recognized tribes or descendents of such members; therefore they are not all eligible for IHS services. However, more than half of the federally recognized American Indian and Alaska Native population does not permanently reside on a reservation and therefore may have limited or no access to IHS services because of their distance from IHS-funded facilities. In addition to its headquarters in Rockville, Maryland, IHS consists of a system of IHS-funded facilities organized into 12 geographic areas of various sizes and containing different types of facilities. Each of the 12 areas has an area office, an administrative body that may include an area director, a chief medical officer, and other staff who oversee the area’s budget and programs. See figure 1 for a map of the counties included in the 12 IHS areas. These facilities are IHS-operated, tribally operated, or overseen by the UIHP. IHS areas include more than 650 of these IHS-funded health care facilities, including hospitals, health centers, health stations, and UIHP facilities. These facilities mainly offer primary care to small, rural populations, with a limited number of larger health care facilities providing specialty care, such as treatment of HIV/AIDS. The types of facilities in each area vary. For example, the California area has no IHS-funded hospitals, while the Aberdeen area has nine small hospitals. The estimated IHS user population in each of the 12 areas ranges from about 24,000 to about 310,000 (see table 1). For fiscal year 2006, Congress appropriated approximately $2.7 billion to IHS to primarily provide direct care at IHS-funded facilities and to purchase care outside of IHS through contracts. From this appropriation, IHS also funds public health nursing, health education, and other functions. In addition, in fiscal year 2006, IHS received reimbursements of $681 million from Medicare, Medicaid, and private health insurance, with Medicare and Medicaid contributing almost 90 percent of those reimbursements. These reimbursements were for treatment at IHS-funded facilities of patients who were eligible for Medicare and Medicaid, in addition to IHS health care. More than 50 percent of IHS’s budget supports tribally operated facilities and around 1 percent supports UIHP facilities. Out of the total appropriated for services, approximately $500 million was designated for contract health services. For services that IHS-funded facilities cannot provide, the contract health services funding is used to purchase care for eligible American Indians and Alaska Natives through contracts with outside providers. For example, contract health services money has been used to purchase specialty care that may not be available at a patient’s local IHS-funded facility, such as behavioral health care. While IHS tracks the overall costs of providing health services, it does not itemize those costs by disease; therefore the agency does not track the cost for its facilities to provide HIV/AIDS prevention and treatment services. According to HHS, efforts are under way—primarily by CDC—to fund prevention programs to educate people at highest risk, as well as the general public, about HIV/AIDS and preventing or reducing their risk. CDC reports that HIV prevention programs can include strategies such as the following. HIV testing and counseling. According to CDC, individuals at risk for HIV should be offered testing and counseling so that they can be aware of their status and take steps to protect their own health and that of their partners. Testing is a key HIV prevention strategy because, as CDC estimates, more than half of HIV infections are transmitted by individuals who are unaware of their infection. Recently available HIV rapid test results are available the same day, in contrast to traditional lab-based testing that can take up to 2 weeks to provide results. Thus rapid testing can help ensure that individuals receive their test result. Moreover, because rapid tests do not require lab facilities or highly trained staff, this type of test can expand access to testing in both clinical and nonclinical settings; however, rapid tests are more expensive than lab-based tests. In addition to testing, counseling services offer patients ways to eliminate or reduce their risk for HIV infection. Partner notification. Sexual or needle-sharing partners of HIV-positive individuals have been exposed to HIV and may be infected. Partner notification services attempt to locate these individuals based on information provided by the patient to provide counseling, education, and other services to prevent infection or, if the individual is infected, provide referrals to care. Health education and risk reduction. Health education provides individuals with the skills and information necessary to avoid or reduce behaviors that put them at risk for HIV infection. Health education services can include individual, group, school, and community interventions, as well as outreach to HIV-positive individuals and HIV- negative individuals at high risk. These services can also include health communication and public information programs for individuals at high risk and the general public. Risk reduction activities can include condom distribution and needle exchange programs. HHS issues guidelines for the medical management of HIV and issues surrounding HIV infection. The guideline documents are periodically reviewed and updated by panels of HIV experts, because concepts relevant to management of HIV change rapidly. The recommended treatment for HIV is a combination of three or more drugs, called Highly Active Antiretroviral Therapy (HAART). HAART is used to slow the progression of HIV/AIDS and has reduced the number of HIV/AIDS deaths, but it may have side effects and requires adherence to complicated drug regimens. Additionally, although these drugs can treat HIV infection, HIV cannot be cured. A 2004 Kaiser Family Foundation report estimated the annual cost for providing these drugs was between $10,000 and $12,000 per patient. Beyond drug regimens, patients with HIV/AIDS may require additional specialized care. According to CDC, proper management of HIV/AIDS involves a complex array of behavioral, psychosocial, and medical services, and therefore referral to a health care provider or facility experienced in caring for HIV-infected patients is advised. Treatment must be tailored to the patient’s needs and may include mental health services, substance abuse services, and medical case management, including treatment adherence services. Patients with HIV/AIDS may also require support services, such as housing or transportation assistance. Patients with HIV/AIDS may face barriers to care. A 1998 study reported that patients with HIV/AIDS in both rural and urban areas experienced barriers to treatment services including a lack of knowledge about the disease, insufficient financial resources, and a lack of employment opportunities. Moreover, the study found that patients with HIV/AIDS in rural areas—compared to their urban counterparts—reported significantly greater need to travel long distances to medical facilities and personnel; a shortage of adequately trained medical and mental health professionals; a lack of personal or public transportation; and community stigma toward people living with HIV. American Indians and Alaska Natives suffer from HIV/AIDS at higher rates than whites and from a range of other medical conditions at higher rates than the general population. CDC estimated that in 2005, a total of 1,581 American Indians and Alaska Natives were living with AIDS in the 50 states and the District of Columbia. CDC’s 2005 surveillance data also showed that of individuals diagnosed with AIDS from 1997 through 2004, American Indians and Alaska Natives died sooner after diagnosis than did individuals of all other races and ethnicities except blacks. In addition, women accounted for 24 percent of the estimated numbers of American Indians and Alaska Natives living with AIDS in 2005, compared with 12.5 percent for whites. The data also showed that the 10 states with the highest number of American Indians and Alaska Natives living with AIDS in 2005 were: (1) California, (2) Arizona, (3) Oklahoma, (4) Washington, (5) New York, (6) Alaska, (7) North Carolina, (8) New Mexico, (9) Minnesota, and (10) Texas. CDC’s estimate of the number of American Indians and Alaska Natives living with AIDS in the 12 IHS areas, which do not cover the entire United States, was 872 in 2005 (see table 2). HIV/AIDS is one of many health concerns facing American Indians and Alaska Natives. While American Indians and Alaska Natives have the third highest rate of HIV/AIDS after blacks and Hispanics, the disease is not one of the top 10 leading causes of death for this population. Some of the major health concerns facing the population include diabetes; heart, liver, and cardiovascular diseases; cancer; unintentional injuries; obesity; substance abuse; and suicide. Given these numerous health concerns, as well as challenges related to poverty and unemployment, the National Alliance of State & Territorial AIDS Directors report that making HIV/AIDS a priority is often difficult for many American Indian and Alaska Native communities. Although HIV/AIDS is not among the major health concerns for the population, American Indians and Alaska Natives experience high rates of risk factors for HIV infection, such as sexually transmitted diseases and poverty-related conditions. According to 2005 CDC surveillance data by race or ethnicity, American Indians and Alaska Natives had the second highest rates of gonorrhea and chlamydia and the third highest rate of syphilis. CDC notes that these rates suggest that the sexual behaviors that facilitate the spread of HIV are relatively common among American Indians and Alaska Natives. In addition to sexually transmitted diseases, alcohol and drug abuse—which are prevalent in the American Indian and Alaska Native community—are risk factors for HIV transmission. Moreover, conditions related to poverty, such as lower levels of education and poorer access to health care, may increase the risk for HIV infection. During 2002 through 2004, approximately one quarter of American Indians and Alaska Natives―about twice the national average―were living in poverty.