Cognitive control as a potential neural mechanism of protective role of spirituality in anxiety disorders among American Indian people: An ERP study.

Research suggests that traditional cultural factors are protective against mental health conditions in American Indian (AI) populations. This study aims to determine if cognitive control is a neurocognitive mechanism of the protective role of spirituality in AI people with generalized anxiety disorder (GAD). Participants self-identified as AI (n = 52) and included individuals with GAD (n = 16) and without GAD (n = 36). Electroencephalography was collected during a stop-signal task to probe cognitive control using the P3 event-related potential. Higher levels of spirituality attenuated the processing efficiency disruption among individuals with GAD as indicated by P3 amplitudes closer to that of individuals without GAD.

Complementary Alternative Medicine: A Culturally Centered Approach to Managing Chronic Pain from One American Indian Community.

This evaluation explored the benefits of Complementary Alternative Medicine (CAM) within a reservation-based, State-certified outpatient treatment provider. The three CAM strategies provided were massage, acupuncture, and chiropractic therapies. The evaluation team worked with a peer recovery support specialist and tribal evaluation intern to co-create a one-page, eight-question, fixed-response instrument based on previous work in the community. Surveys were collected by the peer support specialist post-session with individuals receiving CAM therapies. Surveys assessed self-reported impacts, reasons for attending CAM sessions, and mental, physical, spiritual, and emotional health before and after CAM sessions. Paired t-tests were used to examine significant differences in mean scores before and after CAM sessions. A total of 40 participants completed the survey between March 2021 and March 2022. The evaluation found a significant increase in the mean scores for all measured self-reported health ratings: physical, spiritual, emotional, and mental. The greatest increase observed was for physical health (M = 5.32, SD = 2.53) and physical health after (M = 8.38, SD = 1.60) based on self-report data; t(78) = 6.46, p = .0001. CAM sessions positively influenced participants; 83% (n = 33) reported being more hopeful about their overall health and wellness. The holistic approach demonstrated promising results and potential benefits of CAM on overall wellness and belonging. Further research is needed to explore how CAM may be implemented as a culturally centered approach to managing chronic pain often associated with opioid use disorder.

Metal mixtures and DNA methylation measures of biological aging in American Indian populations.

INTRODUCTION: Native American communities suffer disproportionately from elevated metal exposures and increased risk for cardiovascular diseases and diabetes. DNA methylation is a sensitive biomarker of aging-related processes and novel epigenetic-based "clocks" can be used to estimate accelerated biological aging that may underlie increased risk. Metals alter DNA methylation, yet little is known about their individual and combined impact on epigenetic age acceleration. Our objective was to investigate the associations of metals on several DNA methylation-based aging measures in the Strong Heart Study (SHS) cohort. METHODS: Blood DNA methylation data from 2,301 SHS participants was used to calculate age acceleration of epigenetic clocks (PhenoAge, GrimAge, DunedinPACE, Hannum, Horvath). Urinary metals [arsenic (As), cadmium (Cd), tungsten (W), zinc (Zn), selenium (Se), molybdenum (Mo)] were creatinine-adjusted and categorized into quartiles. We examined associations of individual metals through linear regression models and used Bayesian Kernel Machine Regression (BKMR) for the impact of the total metal mixture on epigenetic age acceleration. RESULTS: The mixture of nonessential metals (W, As, Cd) was associated with greater GrimAge acceleration and DunedinPACE, while the essential metal mixture (Se, Zn, Mo) was associated with lower epigenetic age acceleration. Cd was associated with increased epigenetic age acceleration across all clocks and BKMR analysis suggested nonlinear associations between Se and DunedinPACE, GrimAge, and PhenoAge acceleration. No interactions between individual metals were observed. The associations between Cd, Zn, and epigenetic age acceleration were greater in never smokers in comparison to current/former smokers. CONCLUSION: Nonessential metals were positively associated with greater epigenetic age acceleration, with strongest associations observed between Cd and DunedinPACE and GrimAge acceleration. In contrast, essential metals were associated with lower epigenetic aging. Examining the influence of metal mixtures on epigenetic age acceleration can provide insight into metals and aging-related diseases.

Behavioral health services for urban American Indians and Alaska Natives: A thematic analysis of interviews with 10 program directors.

Urban Indian Health Programs (UIHPs) are one of the primary sources of government-funded health care for the millions of American Indian and Alaskan Native (AI/AN) people living in urban areas. The goal of this study is to better understand what services are available at UIHPs and how resources are being used to support these services. Semistructured interviews with behavioral health directors at 10 UIHPs were reported, transcribed, and thematically analyzed to address this knowledge gap. Our analysis indicates that UIHP behavioral health services were broad, encompassing numerous commitments that extend far beyond purely psychotherapeutic interactions and interventions to the periphery of behavioral health. An accurate accounting of behavioral health services at UIHPs must consider not only the ways that these services are shaped by distinctive visions to provide Indigenous cultural education and traditional healing, but also by expansive commitments to offering a full range of social services, case management, and community building under the broad umbrella of behavioral health. Implications of these findings include the need for additional funding for UIHPs, greater sponsorship of pathway training programs for AI/ANs in the mental health professions to increase the availability of AI/AN providers, future expansion of traditional healing practices, and direct empirical observation of behavioral health service delivery. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Recommendations to improve recruitment and retention of underrepresented in medicine trainees in neonatal-perinatal medicine.

Physicians who identify as Black, Latinx, American Indian, Pacific Islander, and certain Asian subgroups represent racial and ethnic populations that are underrepresented in medicine (URM). While the proportion of URM pediatric trainees has remained unchanged, that of Neonatal-Perinatal Medicine (NPM) fellows has decreased. Informed by the medical literature and our lived experiences, we compiled and developed a list of recommendations to support NPM fellowship programs in the recruitment, retention, and promotion of URM trainees. We describe ten recommendations that address 1) creating a culture of inclusivity and psychological safety, 2) the critical appraisal of recruitment practices and climate, and 3) an inclusive and holistic fellowship application process. The first two themes lay the foundation, while the final theme spotlights our recommendations for URM recruitment. Each recommendation is a step towards improvement in recruitment and inclusion at a program.

Centering culture in the treatment of opioid use disorder with American Indian and Alaska Native Communities: Contributions from a National Collaborative Board.

American Indian/Alaska Native (AI/AN) communities are disproportionally impacted by the opioid overdose epidemic. There remains a dearth of research evaluating methods for effectively implementing treatments for opioid use disorder (OUD) within these communities. We describe proceedings from a 2-day Collaborative Board (CB) meeting tasked with developing an implementation intervention for AI/AN clinical programs to improve the delivery of medications to treat OUD (MOUD). The CB was comprised of Elders, cultural leaders, providers, individuals with lived experience with OUD, and researchers from over 25 communities, organizations, and academic institutions. Conversations were audio-recorded, transcribed, and coded by two academic researchers with interpretation oversight provided by the CB. These proceedings provided a foundation for ongoing CB work and a frame for developing the program-level implementation intervention using a strength-based and holistic model of OUD recovery and wellbeing. Topics of discussion posed to the CB included engagement and recovery strategies, integration of extended family traditions, and addressing stigma and building trust with providers and clients. Integration of traditional healing practices, ceremonies, and other cultural practices was recommended. The importance of centering AI/AN culture and involving family were highlighted as priorities for the intervention.

American Indian and Alaska Native Accessibility to Comprehensive Cleft Lip and Palate Treatment.

American Indians and Alaska Natives (AI/AN) have the highest incidence of cleft lip and palate (orofacial clefts [OFCs]) when compared to other ethnic groups. We aim to determine the AI/AN populations' proximity and accessibility to American Cleft Palate-Craniofacial Association accredited centers (ACPA centers) for treatment of OFCs. Our hypothesis is an unacceptable proportion of the AI/AN population lacks reasonable accessibility to ACPA centers and comprehensive craniofacial care.A cross-sectional study of ACPA centers and AI/AN populations were analyzed for possible disparities.ACPA centers were mapped using Geographic Information Systems (GIS) and compared with 2018 census population data and 2017 Tribal Census Tract data to visually display possible disparities. Total annual potential pediatric cleft care need for selected high-density AI/AN populated lands were estimated.GIS mapping demonstrates geographical isolation of AI/AN populations from ACPA centers. Two states with high AI/AN populated lands (ND, WY) have no ACPA centers. 47.1% of ACPA centers in high AI/AN populated lands have no craniofacial trained surgeons versus 78.9% craniofacial staffed ACPA centers nationally. The potential unmet cleft and craniofacial care need in selected high-density AI/AN populated lands is 1042 children.AI/AN populations are likely underserved by ACPA centers and by craniofacial fellowship-trained staffed centers. Not addressing OFCs with comprehensive care can lead to worsened outcomes and further marginalization of these children. With future studies, we will be capable of making data-driven, informed decisions to more effectively ensure AI/AN access to comprehensive cleft and craniofacial care.

"Treat Me like Your Family": Positive Factors that Influence Patient-Provider Relationships for Native American Women.

Although extensive documentation of the health disparities experienced by Native American peoples exists, little research explores experiences of members of non-federally recognized tribes who receive health care outside of the Indian Health Services (IHS) system. Additionally, positive factors that influence relationships between health care providers and tribal members are understudied and are needed to promote health care access. A qualitative descriptive methodologic approach was used to conduct semi structured life history interviews with 31 women who identified as members of a state-recognized, Gulf South Native American tribe. Results identified the following important themes: Do Participants Have a Regular Provider, Personal Relationship With Provider, Feel Provider Cares, Provider Addresses Concern, and Respect for Traditional or Holistic Medicine. These findings suggest health care providers play an important role in impacting the health care experiences of Native American tribal members. Implications for trainings for health care providers are discussed.

Developing a land-based oral health promotion project with an Indigenous community in northern British Columbia, Canada.

In British Columbia, Canada, First Nations children and youth consistently present with a higher incidence of dental disease. Efforts to improve the oral health status of Indigenous populations have had mixed success, and programs have typically been offered through a Western lens. Recent years have brought calls for oral health professionals to embrace a more holistic approach to health promotion, representative of Indigenous cultures. Colonization has been considered a negative health determinant as it led to the destruction of culture, language, and the removal of Indigenous peoples from their traditional lands. Self-determination and cultural connection are critical to mitigating cultural genocide. Health promotion projects have the potential to support these goals. Fundamental to decolonizing oral health promotion is the development of a sustainable program founded in the traditional ways of Indigenous health and healing. The purpose of this short communication is to report on a collaborative oral health project that used cultural connection as the framework for oral health promotion in a remote Indigenous community.

En Colombie-Britannique, au Canada, les enfants et les jeunes des Premières Nations présentent systématiquement une incidence plus élevée de maladies dentaires. Les efforts visant à améliorer l'état de santé buccodentaire des populations autochtones ont connu un succès mitigé, bien que les programmes aient généralement été offerts dans une optique occidentale. Ces dernières années, les professionnels de la santé buccodentaire ont été appelés à adopter une approche plus globale de la promotion de la santé, représentative des cultures autochtones. La colonisation a été considérée comme un déterminant négatif de la santé, car elle a mené à la destruction de la culture et de la langue, ainsi que l'expulsion des Autochtones de leurs terres traditionnelles. L'autodétermination et le lien culturel sont essentiels pour atténuer le génocide culturel. Les projets de promotion de la santé ont le potentiel de soutenir ces objectifs. L'élaboration d'un programme durable fondé sur les méthodes traditionnelles de santé et de guérison autochtones est essentielle à la décolonisation de la promotion de la santé buccodentaire. L'objectif de cette brève communication est de faire le point sur un projet de santé buccodentaire collaboratif qui a utilisé le lien culturel à titre de cadre pour la promotion de la santé buccodentaire dans une communauté autochtone éloignée.

Sexuality and Gender Identity Inequities in Substance Use Disorder and Its Treatment among American Indian, Alaska Native, and Native Hawaiian College Students.

BACKGROUND: The aim of this study was to investigate inequities in substance use disorder (SUD) diagnosis, opioid misuse, marijuana misuse, SUD treatment utilization, and utilization of university mental health services among sexual and gender minority (SGM) American Indian, Alaska Native, and Native Hawaiian (AI/AN/NH) college students. METHODS: Data consisting of 8,103 AI/AN/NH students' responses to the American College Health Association's National College Health Assessment survey from fall 2015 through spring 2019 were utilized for this study. Multivariable logistic regression models were used to compare the odds of SUD diagnosis, opioid misuse, and marijuana misuse in SGM AI/AN/NH students to cisgender, heterosexual peers. Unadjusted odds of SUD treatment utilization and utilization of university mental health services were also evaluated. RESULTS: Compared to cisgender females, transgender (aOR = 4.43, 95% CI = 2.67-7.34) and gender diverse (aOR = 2.86, 95% CI = 1.61-5.07) students had significantly higher odds of SUD diagnosis. Similarly, significantly higher odds of SUD diagnosis were observed among sexual minorities, including gay/lesbian (aOR = 2.95, 95% CI = 1.71-5.09) and bisexual (aOR = 1.97, 95% CI = 1.30-2.99) students compared to heterosexual peers. Sexual minority students had significantly higher odds of utilizing university mental health services (uOR = 2.43, 95% CI = 1.22-4.84) than heterosexual peers. Odds of opioid misuse and marijuana misuse were also significantly increased among sexual minority students. CONCLUSIONS: AI/AN/NH college students who identify as SGM have higher odds of SUD diagnosis, opioid misuse, and marijuana misuse than their cisgender, heterosexual peers. These findings highlight the need to consider tailored programming for SGM AI/AN/NH students in substance use prevention and intervention efforts in U.S. college settings.

KCNQ5 activation by tannins mediates vasorelaxant effects of barks used in Native American botanical medicine.

Tree and shrub barks have been used as folk medicine by numerous cultures across the globe for millennia, for a variety of indications, including as vasorelaxants and antispasmodics. Here, using electrophysiology and myography, we discovered that the KCNQ5 voltage-gated potassium channel mediates vascular smooth muscle relaxant effects of barks used in Native American folk medicine. Bark extracts (1%) from Birch, Cramp Bark, Slippery Elm, White Oak, Red Willow, White Willow, and Wild Cherry each strongly activated KCNQ5 expressed in Xenopus oocytes. Testing of a subset including both the most and the least efficacious extracts revealed that Red Willow, White Willow, and White Oak KCNQ-dependently relaxed rat mesenteric arteries; in contrast, Black Haw bark neither activated KCNQ5 nor induced vasorelaxation. Two compounds common to the active barks (gallic acid and tannic acid) had similarly potent and efficacious effects on both KCNQ5 activation and vascular relaxation, and this together with KCNQ5 modulation by other tannins provides a molecular basis for smooth muscle relaxation effects of Native American folk medicine bark extracts.

Blood cadmium, lead, manganese, mercury, and selenium levels in American Indian populations: The Strong Heart Study.

BACKGROUND: Many American Indian (AI) communities are in areas affected by environmental contamination, such as toxic metals. However, studies assessing exposures in AI communities are limited. We measured blood metals in AI communities to assess historical exposure and identify participant characteristics associated with these levels in the Strong Heart Study (SHS) cohort. METHOD: Archived blood specimens collected from participants (n = 2014, all participants were 50 years of age and older) in Arizona, Oklahoma, and North and South Dakota during SHS Phase-III (1998-1999) were analyzed for cadmium, lead, manganese, mercury, and selenium using inductively coupled plasma triple quadrupole mass spectrometry. We conducted descriptive analyses for the entire cohort and stratified by selected subgroups, including selected demographics, health behaviors, income, waist circumference, and body mass index. Bivariate associations were conducted to examine associations between blood metal levels and selected socio-demographic and behavioral covariates. Finally, multivariate regression models were used to assess the best model fit that predicted blood metal levels. FINDINGS: All elements were detected in 100% of study participants, with the exception of mercury (detected in 73% of participants). The SHS population had higher levels of blood cadmium and manganese than the general U.S. population 50 years and older. The median blood mercury in the SHS cohort was at about 30% of the U.S. reference population, potentially due to low fish consumption. Participants in North Dakota and South Dakota had the highest blood cadmium, lead, manganese, and selenium, and the lowest total mercury levels, even after adjusting for covariates. In addition, each of the blood metals was associated with selected demographic, behavioral, income, and/or weight-related factors in multivariate models. These findings will help guide the tribes to develop education, outreach, and strategies to reduce harmful exposures and increase beneficial nutrient intake in these AI communities.

A Culture and Wellness Pilot to Guide Community Engaged Public Health Research in Native American Populations.

BACKGROUND: Alaskan Native/American Indian (AI/AN) participation in biomedical sciences is often hindered by cultural miscommunication regarding concepts and definitions of health. Identifying culturally contextualized health priorities is crucial to building research collaborations between academic institutions and AI/AN consortia. METHODS: This article describes pilot data from the development of a culture and wellness questionnaire deployed by the Great Lakes Native American Research Center for Health at cultural events and community engagement meetings. The questionnaire was designed in collaboration with AI/AN members to assess performance indicators of public health promotion in AI/AN populations who are culturally inclined to interpret health holistically. RESULTS: There were 25 completed questionnaires. Connection to the land (88%) and "giving thanks" (96%) were the most prominently affirmed health and wellness concepts. Participants were least confident (33%) in the ability to support the next generation culturally (language, stories, etc). These results comport with anecdotal data that AI/AN concepts of health and wellness should be co-developed with AI/AN cultural leaders and community members. Future implications for academic partnerships are discussed.

"Calling the Spirit Back:" Spiritual Needs Among Great Plains American Indians.

CONTEXT: American Indians (AIs) are disproportionately affected by serious illness such as cancer. Colonization, cultural genocide, and trauma have adversely affected AIs' ability to attain health and well-being, and in many cases led to the loss of the right to practice traditional ceremonies and rituals. Still many AIs describe well-being as being rooted in spirituality. OBJECTIVES: The purpose of this project was to learn about the perspectives of AI cancer survivors, caregivers, and Tribal leaders and healers specific to spirituality while on the cancer journey. METHODS: Qualitative interviews and Indigenous talking circle methodologies were used to explore AIs cancer survivors, caregivers, and Tribal leaders and healers' perspectives on spirituality while on the cancer journey. A data analysis team consisting of AI and non-AI members analyzed the narrative data. RESULTS: Qualitative analysis of interviews and talking circles revealed 4 major themes related to spirituality: the chasm of colonialism, coexistence of Traditional and Christian religions, calling the Spirit back, and prayer as sacred energy. CONCLUSION: It is critical that clinicians caring for AIs with serious illness seek to understand their patients' spiritual beliefs about disease treatment and death and work with them and their families to support quality of life throughout their illness journey. In addition, clinicians must recognize the systemic racism inherent in our healthcare systems, and dismantle cultural clashes and bias for all patients, particularly AIs, who have long suffered from poorer health outcomes.

Diné (Navajo) Female Perspectives on Mother-Daughter Cultural Assets Around the Transition to Womanhood: A Qualitative Study.

INTRODUCTION: American Indian (AI) people have protective factors embedded in cultural teachings that buffer against high-risk behaviors. This study applies a qualitative, grounded theory approach to identify cultural assets for a Diné (Navajo) mother-daughter intervention aimed at preventing substance abuse and teen pregnancy. METHOD: Focus groups and in-depth interviews were conducted with 28 AI females' ages 8 years and older from the Navajo Nation. RESULTS: Key themes were (a) preserving the Diné way of life, (b) cultural assets related to being a healthy Diné woman, (c) matrilineal networks as a source of strength/pride, (d) historical trauma as a source of resilience, (e) male influences as protective health factors, (f) Western education as a measure of success, and (g) integrating different belief systems. DISCUSSION: Study findings may be applied as foundational elements for culturally grounded AI substance abuse and teen pregnancy prevention strategies, as well as culturally safe nursing practice.

Key demographic and mental disorder diagnostic differences between Australian First Nations and non-First Nations clinic-referred children and adolescents assessed in a culturally appropriate and safe way.

OBJECTIVE: Increased point prevalence rates of oppositional defiant disorder and conduct disorder have been reported in American Indian and Canadian First Nations children and adolescents. To date, in Australia, there has been no published examination of standardized Diagnostic and Statistical Manual mental disorder diagnoses in First Nations children and adolescents, determined after addressing key cultural methodological issues. METHODS: In all, 113 First Nations children and adolescents and 217 non-First Nations young people, aged 6-16 years, age, gender, mental disorder symptom severity, symptom-linked distress and impairment matched were recruited in a case control study. Also, 112 typically developing non-First Nations participants, age and gender matched to the other two clinical groups as a second comparison group were recruited. Diagnostic and Statistical Manual mental disorder diagnoses via semi-structured clinical interview, social adversity status and full scale IQ were determined in all participants with cultural validity and reliability of the impairing patterns of symptoms in First Nations young people determined by First Nations mental health staff and Aboriginal Health Liaison Officers. Full scale IQ and social adversity status were appropriately controlled in the Logistic Regression analyses of Diagnostic and Statistical Manual mental disorder diagnoses between the two clinical groups. RESULTS: Oppositional defiant disorder was the only diagnostic and statistical manual mental disorder diagnosis that differed between the First Nations and non-First Nations clinical groups, adjusting for confounding by social adversity status and full scale IQ in the multivariable model. The point prevalence of oppositional defiant disorder was 2.94 times higher (95% confidence interval: 1.14-7.69) among the First Nations compared to the non-First Nations clinical group. CONCLUSION: Key known risk factors for oppositional defiant disorder can be identified early and holistically managed in First Nations young people. This will prevent oppositional defiant disorder decreasing their access to mental health services and increasing their involvement in the criminal justice system. In addition, the resilience building aspects of oppositional defiant disorder that may enhance self-respect need to be nurtured.

In Our Sacred Voice - An Exploration of Tribal and Community Leader Perceptions as Health Communicators of Disease Prevention among American Indians in the Plains.

American Indians (AI) are disproportionately and significantly impacted by disease morbidity, mortalityand poor behavioral health outcomes. Health promotion and health communication programs exist to address these health disparities and health conditions; however, few programs fully integrate holistic approaches when targeting AI populations. The objective of this study was to explore how tribal and community leaders throughout the Central Plains (Kansas, Iowa, Missouri, and South Dakota) viewed themselves as health communicators and health promoters within their communities. Members of the Center for American Indian Community Health (CAICH) conducted 39 in-depth interviews with members of federally recognized tribes living in reservation communities as well as urban tribal communities across the region. Results from the sample show that these individuals do not necessarily see themselves as the "authority" health communicator or health promoter within their tribe or community. They did perceive themselves and others as gatekeepers of pertinent health information. Social and cultural authority within culturally centered messaging and collective delivery of this type of health information from trusted sources within tribes and communities is perceived to bolster health communication programs and positively impact health outcomes among AI populations.

Federal Statutes and Environmental Justice in the Navajo Nation: The Case of Fracking in the Greater Chaco Region.

Arguing for the importance of robust public participation and meaningful Tribal consultation to address the cumulative impacts of federal projects, we bridge interdisciplinary perspectives across law, public health, and Indigenous studies. We focus on openings in existing federal law to involve Tribes and publics more meaningfully in resource management planning, while recognizing the limits of this involvement when only the federal government dictates the terms of participation and analysis. We first discuss challenges and opportunities for addressing cumulative impacts and environmental justice through 2 US federal statutes: the National Environmental Policy Act and the National Historic Preservation Act. Focusing on a major federal planning process involving fracking in the Greater Chaco region of northwestern New Mexico, we examine how the Department of the Interior attempted Tribal consultation during the COVID-19 pandemic. We also highlight local efforts to monitor Diné health and well-being. For Diné people, human health is inseparable from the health of the land. But in applying the primary legal tools for analyzing the effects of extraction across the Greater Chaco region, federal agencies fragment categories of impact that Diné people view holistically. (Am J Public Health. 2022;112(1):116-123. https://doi.org/10.2105/AJPH.2021.306562).

The Care of American Indian Children in North Carolina: Protecting Our Future and Our Heritage.

Native American children face many different challenges when it comes to their health. They are predisposed to an increased rate of diseases such as diabetes and asthma. Traditional medicine is still practiced in many Native communities. As health care professionals, we must be culturally sensitive to their needs. One way to improve Native health care is to increase the number of Native physicians practicing in their communities.

Ten millennia of hepatitis B virus evolution.

Hepatitis B virus (HBV) has been infecting humans for millennia and remains a global health problem, but its past diversity and dispersal routes are largely unknown. We generated HBV genomic data from 137 Eurasians and Native Americans dated between ~10,500 and ~400 years ago. We date the most recent common ancestor of all HBV lineages to between ~20,000 and 12,000 years ago, with the virus present in European and South American hunter-gatherers during the early Holocene. After the European Neolithic transition, Mesolithic HBV strains were replaced by a lineage likely disseminated by early farmers that prevailed throughout western Eurasia for ~4000 years, declining around the end of the 2nd millennium BCE. The only remnant of this prehistoric HBV diversity is the rare genotype G, which appears to have reemerged during the HIV pandemic.