This issue came up in a discussion with LisaRNelson in the 2023-06-02 V2 Management Notes. Please involve her in any discussions.

For consistency with the USCDI Tribal Affiliation data element and the FHIR US Core Tribal Affiliation Extension we need a way to represent tribal affiliation in V2 Messaging. A patient may be informally affiliated with a tribe without being an enrolled legal citizen of that tribe. This is relevant to SDOH. For example, the patient might be affiliated with a tribe by living on tribal land or being married to a tribal citizen..
V2MG members discussed two potential solutions.

1. Rename PID-39 from "Tribal Citizenship" to "Tribal Citizenship or Affiliation", and update the definition accordingly. This would maintain backward compatibility and be fairly easy to implement, however it wouldn't clearly distinguish between affiliation versus legal citizenship which might create issues when mapping V2 to CDA and FHIR.
2. Add a new optional repeating PID-41 "Tribal Affiliation" field (suggested by RikiM). This would require more software changes for implementers, but it would explicitly differentiate between citizenship versus affiliation and would allow a cleaner mapping to CDA and FHIR.

PA members might be able to think of other options beyond those two.