A Navajo reservation on the Arizona-New Mexico border has seen its HIV diagnoses go up by 20 percent since 2011. Despite a concerted push by the federal Indian Health Service (IHS) and public health advocates to expand tribal HIV education programs, doctors have found treatment and prevention efforts to be stymied by cultural stigma surrounding the disease and homosexuality.

Since the Navajo tribe is a comparatively isolated population, the topline numbers of HIV infections among tribe members are relatively low, and at least part of the rise is attributable to enhanced screening efforts. However, that same seclusion allows stigma and the fear of community repercussion to prevent infected Navajo men from seeking care once they are diagnosed. “Our communities are very small, and that can lead to people avoiding stigma, rather than getting the care they need,” IHS chief medical officer Dr. Susan V. Karol told the New York Times.