Department of State Health Services

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1 TEXAS Department of State Health Services Department of State Health Services HIV/STD PROGRAM 2007 ANNUAL REPORT David L. Lakey, M.D. Commissioner Sharon K. Melville, M.D., M.P.H., Manager HIV/STD Epidemiology and Surveillance Branch Ann S. Robbins, Ph.D., Manager HIV/STD Comprehensive Services Branch

2 TABLE OF CONTENTS List of Figures and Tables I. Executive Summary II. HIV/STD Program Overview III Epidemiologic Profi le of HIV and AIDS in Texas IV Epidemiologic Summary of STD in Texas V. HIV Prevention Services HIV Perinatal Prevention HIV Prevention Planning HIV Prevention Contracts and Monitoring VI. HIV Medical and Support Services HIV Medical and Support Services Planning HIV Clinical Resources Housing Opportunities for People with AIDS VII. Texas HIV Medication Program VIII. Estimates of Unmet Need for HIV-Related Medical Care in Texas.. 55 IX. STD Prevention and Care Services Syphilis Elimination - Texas Texas Infertility Prevention Project X. HIV/STD Training XI. HIV/STD Health Promotion ACKNOWLEDGEMENTS The DSHS HIV/STD Program recognizes and thanks the following staff for their contributions to this report: Robert Aguirre, John Allen, Dolores Alvarez, Susan Aulds, Greg Beets, Casey Blass, Katharine Carvelli, Mitch Chappell, Janina Daves, Shiloh Davis, Ellen Fontana, Tammy Foskey, Sandra Galnor, Jean Gibson, Dianne Green, Dwayne Haught, Rebecca Herron, Jessica Hills, Liza Hinojosa, Jeff Hitt, Jim Lee, Jenny McFarlane, Sharon Melville, Alicia Nelson, Niki Pham, Michelle Porter, Ann Robbins, Tammy Sajak, Jamie Schield, Tony Schmitt, Rebecca Sorensen, Mary VanWisse, John Waara, Dan Warr, Ed Weckerly, Katherine Wells, and Janna Zumbrun. 2

3 FIGURES 1. Number of People Living with HIV/AIDS, Texas Number of New Diagnoses of HIV Disease and Deaths, Texas Persons Living with HIV/AIDS by Age Group, Texas 2003 and Number and Rate of Persons Living with HIV/AIDS by Race/Ethnicity, Texas, Persons Living with HIV/AIDS by Mode of Exposure, Texas, Comparison of Count and Rate of New HIV Diagnosis by Race/Ethnicity, Texas Persons Diagnosed with HIV and AIDS within One Month or One Year, Texas Geographic Areas of Interest Proportion of Persons Living with HIV/AIDS by Area, Texas Rate of Persons Living with HIV/AIDS by Geographic Area, Texas, Primary and Secondary Syphilis Cases: Texas, Primary and Secondary Syphilis Case Rates by Race/Ethnicity: Texas, Syphilis Case Rates: Texas, Chlamydia Cases: Texas, Chlamydia Case Rates Among Women by Race/Ethnicity: Texas, Gonorrhea Cases: Texas, Gonorrhea Case Rates by Race/Ethnicity: Texas, An Overview of Planning Areas in Texas Number of Texas HIV Medication Program Clients Served by Race/Ethnicity, FY Number of Texas HIV Medication Program Clients Served by Age Group, FY Number and Proportion of Persons with an Unmet Need for Medical Care by Select Characteristics, Texas Unmet Need among Persons Living with HIV/AIDS by Geographic Area, Texas Disease Intervention Process TABLES 1. Persons Living with HIV/AIDS by Select Characteristics, Texas, 2003 and New HIV/AIDS Diagnoses by Select Characteristics, Texas Number and Rate of New Diagnoses by Sex and Race/Ethnicity, Texas New HIV/AIDS Diagnoses by Sex, Mode of Exposure, and Race/Ethnicity, Texas Selected Characteristics of Persons Diagnosed with HIV and AIDS within One Month or One Year, Texas Persons Living with HIV/AIDS, Select Characteristics by Area, Texas Subpopulations of PLWHA Prevalence Greater than One Percent, Texas

4 8. Participation in Funded HIV Prevention Interventions, Counseling, Testing and Referral: Tests and Positives by Sex and Race/ Ethnicity, Counseling, Testing and Referral: Tests and Positives by Sex and Risk Behavior, Ben Taub Results of Rapid HIV Testing Protocol Initiative at Labor and Delivery Sites (Intervention Performed in June 2007) LBJ Results of Rapid HIV Testing Protocol Initiative at Labor and Delivery Sites (Intervention Performed in July 2007) Persons Living with HIV/AIDS and Services Clients by Select Characteristics, Texas, All Services Clients and Core Services Clients by Select Characteristics, Texas, Overview of Services Provided Statewide, Unmet Need among Persons Living with HIV/AIDS by Mode of Exposure, Race/Ethnicity and Sex, Texas

5 I. EXECUTIVE SUMMARY The mission of the Department of State Health Services (DSHS) HIV/STD Program is to identify, report, prevent, and control human immunodefi ciency virus (HIV), acquired immunodefi ciency syndrome (AIDS), and sexually transmitted disease (STD) in Texas. This 2007 HIV/STD Program Annual Report is respectfully submitted to meet the requirements of Section of the Texas Health and Safety Code. It is based on the calendar year January 1, 2007 through December 31, 2007, unless otherwise noted. Portions of the report are based on specifi c project periods or the State of Texas fi scal year (FY), September 1, 2006 through August 31, 2007 (FY 2007) and are noted as such. HIV/AIDS in Texas There were 62,714 people living with HIV/AIDS (PLWHA) in Texas in 2007, a 30 percent increase from PLWHA fi ve years earlier in The number of new diagnoses has remained stable over the past fi ve years, increasing slightly from 4,612 in 2003 to 4,784 in From 2003 through 2007, over one quarter of all new diagnoses in Texas received an AIDS diagnosis within one month of their HIV diagnosis, indicating that a substantial proportion were not diagnosed until late in the progression of HIV disease. Also, many subpopulations in the largest metropolitan areas of the state had PLWHA prevalence rates above 1,000 per 100,000 population (i.e. one percent of the population in question). African American men over 35 years of age were the most affected subpopulation in each metropolitan area. One in 378 Texans is living with HIV/AIDS. One in 112 African American Texans. One in 498 White Texans. One in 565 Hispanic Texans. STD in Texas STD case reports are on the rise in Texas. In 2007, 122,118 STD infections, excluding HIV/ AIDS, were reported in Texas a 10 percent increase from 110,550 cases in A total of 5,573 cases of syphilis were reported, up 12 percent from 4,961 cases reported in Reports of chlamydia totaled 84,784, up from 75,319 cases in The number of gonorrhea case reports increased from 30,270 in 2006 to 31,761 in In Texas, STDs continue to affect the African American population more than any other racial or ethnic group. 5

6 HIV/STD Expenditures The HIV/STD Program receives federal and state funding for HIV and STD prevention and care services. The total HIV/STD program expenditures for FY 2007 were $131.9 million. 1 Of this, nearly 61 percent, or $79.9 million, was provided by federal HIV and STD grants. The remaining 39 percent, or $51.9 million, was provided by state funds and appropriated receipts. More than half of these funds are used to operate the Texas HIV Medication Program (THMP). THMP provides medication to low income Texans who are uninsured or underinsured, accounting for $74.2 million, or 56.3 percent of total funds. A total of $20.4 million (15.5%) was spent for prevention and surveillance, $37.2 million (28.2%) for medical and social support services; direct services funds are distributed to DSHS regional programs, local health departments, and community-based organizations through competitive and non-competitive means. For FY 2007, the Texas Legislature approved an increase of about $8.3 million in General Revenue to support the ability of the Texas HIV Medication Program to provide life-saving medications to a growing number of Texans with HIV disease. HIV Prevention HIV prevention efforts in Texas continue to focus on high-risk target populations identifi ed through the community planning process. DSHS HIV prevention contractors provided 39,232 individual-level, group-level, and community-level HIV behavioral interventions in Contractors conducted 32,800 HIV tests in 2007, with a positivity rate of 1.5 positives for every 100 tests performed, up from 1.22 in The DSHS HIV/STD Program planned and presented the 2007 HIV Prevention Kick-Off on September 11-12, 2007 in Austin. This capacity building event provided new DSHS HIV prevention contractors with instructions, tools, and technical assistance to assist in operating their programs for the contract period. HIV Medical and Support Services During 2007, 28,852 clients received HIV-related medical and social support services from Ryan White funded providers. A total of 2,416 clients with HIV/AIDS and their families received services through the Housing Opportunities for Persons with AIDS Program (HOPWA) in DSHS Legislative Appropriations Request, FY The HOPWA project period was from February 1, 2007 to January 31,

7 Texas HIV Medication Program The Texas HIV Medication Program (THMP) provided 223,248 prescriptions to 13,068 clients in FY These antiretroviral and other HIV prophylactic medications help delay the onset of symptomatic disease and prevent opportunistic infections in persons living with HIV/AIDS. STD Prevention and Care Prevention activities provided by STD programs throughout the state located, counseled, and tested 4,834 HIV sex/needle sharing partners and high-risk social network contacts. Among those tested, 267 new HIV-infected persons were identifi ed. Disease Intervention Specialists also interviewed and managed 2,586 early syphilis cases in A total of 1,408 new cases of syphilis were identifi ed and treated, and 1,501 persons were preventively treated for syphilis. The Gonorrhea Screening Program tested 209,615 persons, identifi ed 10,835 positives (5.2 percent), and confi rmed treatment on 10,693 (99 percent) of those infected. The Chlamydia Screening Program tested 202,270 persons, identifi ed 18,286 positives (9 percent), and confi rmed treatment on 17,863 (98 percent). Training HIV/STD Program staff trained 362 HIV/STD health professionals through 30 trainings in The team also conducted ten visits to ten agencies during the year to provide initial technical assistance, observation and feedback, and three-month informal site reviews related to implementation of protocol-based counseling. Health Promotion In 2007, the HIV/STD Program conducted two social marketing campaigns, one targeting African American men who have sex with men (MSM) ages 18-49, and one targeting African American women ages The objective for the African American MSM campaign was to encourage the population to learn their HIV status and to embrace other preventative health measures such as consistent condom use and seeking regular medical care. This campaign began in Dallas and Houston in October The African American women s campaign focused on encouraging HIV-positive women to seek treatment in addition to encouraging women who do not know their status to get tested. This campaign began in Dallas, Houston, Austin, Beaumont/Port Arthur, and Tyler/Longview in October HIV/STD Program staff participated in a workgroup convened in response to a new state law that requires DSHS to provide educational materials about FDA-approved vaccines against HPV. In 2007, DSHS staff revised the HIV/STD Program s HPV educational materials and training to comply with state legislative requirements. For additional information on DSHS HIV/STD Program activities, please call (512) or visit 7

8 II. HIV/STD PROGRAM OVERVIEW The DSHS HIV/STD Program prevents the spread of HIV and other STDs and minimizes disease complications and costs by providing education, counseling, screening and testing, partner elicitation and notifi cation, and medical and social services. To accomplish this mission, the program conducts surveillance, epidemiologic assessment, research and program evaluation, planning, data management, policy development, monitoring, training, technical assistance, health promotion, and development activities. State general revenue and numerous federal grants support these activities. The program provides some of these services directly, most notably the Texas HIV Medication Program. However, local health departments and community-based organizations provide most public health and client services through contracts with the program. Brief descriptions of major program activities are included below. The HIV/STD Program consists of two branches, the HIV/STD Epidemiology and Surveillance Branch and the HIV/STD Comprehensive Services Branch. Within the DSHS organizational structure, the HIV/STD Epidemiology and Surveillance Branch is located in the Epidemiology and Surveillance Unit, while the HIV/STD Comprehensive Services Branch is located in the Health Promotion Unit. Both these units are in the Disease Prevention and Intervention Section of the Division of Prevention and Preparedness Services. The program includes central offi ce (Austin) staff and regional staff. (Note: Changes in organizational structure including the HIV/ STD Program are to be implemented in late However, the above structure was in place during the period covered by this report.) HIV/AIDS Medical and Support Services In 1990, Congress adopted federal legislation mandating HIV clinical and support services as the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act. In 2006, the act underwent a major reauthorization as the Ryan White HIV/AIDS Treatment Modernization Act. The grant, administered by the Health Resources and Services Administration (HRSA), provides funds to cities, states, and community organizations in fi ve parts: Part A grants go to eligible metropolitan areas (Dallas and Houston) and transitional grant areas (Fort Worth, San Antonio, and Austin) to provide medical and support services for persons living with or affected by HIV/AIDS; Part B grants go to states and territories to provide medical and support services for persons living with or affected by HIV/AIDS; Part C grants support HIV clinical early intervention services; Part D grants support services for women, infants, children, and youth; and Part F grants fund Special Projects of National Signifi cance, AIDS Education Training Centers, dental programs, and the Minority AIDS Initiative (MAI). 8

9 The DSHS HIV/STD Program receives funds and administers programs under Part B and Part F, including HIV medications, HIV medical and social support services and program administration, planning, and quality management. HIV Medications: The grant provides federal funds for the Texas HIV Medication Program (THMP) to purchase medications shown to be effective in reducing hospitalizations and the general deterioration of health due to HIV-related conditions. HIV Medical and Social Support Services: The grant provides funds for the provision of HIV medical and social support services. DSHS and its administrative agencies (AA) contract with providers across the state to provide these services directly to clients. Program Administration, Planning, and Quality Management: The HIV/STD Program provides broad oversight of administrative and congressionally mandated planning and quality management activities for the grant program. DSHS contracts with AA strategically located across the state to assist with these functions. The AA contract with and monitor medical and support service providers and develop and implement Area HIV Comprehensive Services Plans. Ryan White Minority AIDS Initiative The purpose of the Minority AIDS Initiative (MAI) is to provide outreach and education services to increase the number of eligible racial and ethnic minorities who have access to treatment through the Texas HIV Medication Program (THMP). The target populations include African Americans, Hispanics, and others with HIV in Texas. In addition, MAI also provides for outreach to minority HIV positive persons who are: 1) incarcerated in federal, state, or local adult and juvenile institutions; or 2) recently released from incarceration. Housing Opportunities for Persons with AIDS The Housing Opportunities for Persons with AIDS (HOPWA) Program provides housing assistance and supportive services to income eligible persons living with HIV/AIDS and their families. The purpose of the program is to establish or better maintain a stable living environment in housing that is decent, safe, and sanitary, to reduce the risk of homelessness, and to improve access to health care and supportive services. The DSHS HIV/STD Program receives funds from the United States Department of Housing and Urban Development (HUD) for the HOPWA Program. HIV/AIDS Care Services Planning The purpose of HIV/AIDS care services planning is to develop a plan that identifi es, prioritizes, and allocates funding to the most important HIV medical and support services for a particular community with the goal of enrolling and maintaining people living with HIV/AIDS (PLWHA) 9

10 in medical care. HIV/AIDS care services planning is a data-driven process that includes the epidemiologic profi le, qualitative and quantitative community assessment data, and expenditure and client utilization data. Area Comprehensive HIV Care Services Plans and Needs Assessments are available at the DSHS website. HIV care services planning is complex, as there are multiple Ryan White grants in the state and each has unique contractual requirements. The two Eligible Metropolitan Areas (EMAs), Houston and Dallas, and three Transitional Grant Areas (TGAs), Austin, Fort Worth, and San Antonio, receive direct Ryan White Part A funds. Part A requires that planning councils be convened to carry out planning and allocation activities. DSHS allows planning councils to plan for use of Ryan White Part B funds in their area. DSHS contracts with administrative agencies (AA) to conduct required activities for Ryan White Part B funds outside of the EMA/TGAs. Even though separate entities conduct prevention and services planning activities, there is significant collaboration that occurs between planning entities. HIV care services plans are developed by AA and Part A Planning Councils and identify and prioritize specifi c HIV care service categories, allocate funding to those services, and provide implementation strategies to maximize access to and impact of federal and state HIV care funds. Data are used to identify needed services, gaps in care, barriers in access to care, and client usage patterns. AA for both Part A and B use the plans to fund care services across the state through a competitive process. HIV/AIDS care services planning activities for 2007 are addressed in Section VI of this report. HIV Prevention Services The HIV Prevention Cooperative Agreement, administered by the Centers for Disease Control and Prevention (CDC), funds HIV prevention activities throughout Texas. Local providers, including local health departments, university-based programs, and community based organizations, receive HIV prevention funds from DSHS through a competitive application process. There are many other direct CDC awards for HIV prevention activities in the state to other entities for specifi c activities, as well as a cooperative agreement with the City of Houston similar to the state award. Program activities target individuals infected with HIV or at risk of infection for HIV. The purpose of the HIV prevention grant is to assist local communities to: prevent the transmission of HIV or reduce the number of new infections; increase the number of persons who know their HIV status; reduce associated morbidity and mortality among HIV-infected persons and their partners by assuring referral to medical, social, and prevention services; and initiate needed HIV prevention services according to area HIV prevention plans. Activities supported with these funds include HIV counseling, testing, and referral; health education and risk reduction; perinatal transmission prevention; social marketing campaigns; and partner notifi cation services. 10

11 Counseling, Testing, and Referral Services (CTR): Funds are used to contract with providers across the state for targeted testing of high-risk individuals, results delivery and providing partner services for HIV positive clients. The goals of CTR are to prevent HIV transmission, increase the number of people who know their HIV status, and assure referral of infected persons and their partners to care and prevention. Health Education and Risk Reduction (HERR): Funds provide for individual, group and community level interventions that are evidence-based. 1 These programs recruit high-risk individuals to participate in single or multi-session interventions to reduce the risk of HIV transmission. Perinatal Transmission Prevention: Perinatal HIV prevention funds provide for local community based organizations to provide outreach to HIV positive women of childbearing age, intensive case management, and linkage to care for HIV-positive women. One public hospital district works with area hospitals to implement rapid HIV testing for pregnant women delivering at hospitals. Social Marketing Campaigns: Funds provide for targeted social marketing campaigns for high-risk populations. Messages intend to raise awareness, promote healthy behaviors, and/or get people into care. Partner Notifi cation Services: Funds awarded to local health departments support Disease Intervention Specialists (DIS). DIS are responsible for providing partner services activities, including fi eld investigations to notify individuals of their HIV and STD status, conducting partner elicitation interviews, referring patients to medical and social services, conducting case management, and performing partner notifi cation activities. HIV/STD Prevention Services Planning The goal of HIV/STD prevention community planning is to foster a partnership between community stakeholders and DSHS to develop a comprehensive HIV/STD prevention plan that identifi es community prevention needs. The plan prioritizes target populations, identifi es priority prevention issues for each population, and recommends interventions and strategies to address the issues. HIV/STD prevention community planning is a data-driven process that uses the statewide and local epidemiologic profi les, as well as quantitative and qualitative comprehensive assessment data. In late 2006, DSHS convened one, statewide Texas HIV/STD Prevention Community Planning Group (TxCPG) to carry out HIV/STD prevention planning activities for Texas. The TxCPG replaced six regional CPGs that had the responsibility for creating six region-specifi c HIV/STD 1. Evidence-based interventions represent the strongest HIV behavioral interventions in the literature to date that have been rigorously evaluated and have demonstrated effi cacy in reducing HIV or STD incidence or HIV-related risk behaviors or promoting safer behaviors. 11

12 Prevention Action Plans. The new TxCPG has the responsibility to create one, state HIV/ STD Prevention Action Plan that refl ects the uniqueness and vast geography of Texas and its population. The state HIV/STD Prevention Action Plan prioritizes target populations and recommends specifi c intervention strategies based on data collected through assessments and other methods. From this plan, DSHS allocates funding for prevention and testing efforts. Primary goal of this process is to provide a framework of activities designed to prevent new HIV and STD infections. TxCPG will release a new, comprehensive state HIV/STD Prevention Action Plan in HIV/STD prevention services planning activities for 2007 are addressed in Section V of this report. STD Prevention and Care Services The Comprehensive STD Prevention Systems (CSPS) grant, a CDC-funded initiative, provides funds for local health departments and the HIV/STD Program to provide disease intervention, disease surveillance, training, and testing for STDs, including HIV. The STD-related infertility prevention component of the grant provides funds for chlamydia and gonorrhea testing, laboratory services, and quality assurance in STD clinics, DSHS-supported community and family planning clinics, and state and local adult and juvenile correctional facilities. The syphilis elimination component of the grant provides funding to local health departments and community-based organizations for enhanced disease surveillance, community involvement, clinical and laboratory services, and health promotion in areas of Texas with unusually high incidence of syphilis. CSPS also funds the Gonococcal Isolate Surveillance Project in Dallas County. STD/HIV Prevention Training Center The purpose of the Prevention Training Center is to provide high quality training in diagnosis, treatment, and prevention of STD and HIV for healthcare professionals and prevention specialists across the U.S. The HIV/STD Program contracts with the Dallas County Health Department to provide training on STD and partner counseling and referral services to health professionals in the 13-state Southern quadrant of the U.S. Viral Hepatitis Prevention The DSHS HIV/STD Program receives CDC funds through the Adult Viral Hepatitis Coordination grant to improve the delivery of viral hepatitis prevention services in health-care settings and public health programs that serve adults at risk for viral hepatitis. This project aligns with other current DSHS program efforts by the HIV/STD Program, Immunizations Program, and initiatives through the Infectious Disease Control Unit, the Refugee Health Program, the substance abuse block grant, and the 2002 Hepatitis C Action Plan for Texas. 12

13 Disease Surveillance Activities HIV/AIDS Surveillance The purpose of the CDC-funded HIV/AIDS Surveillance Project is to design, implement, and maintain core surveillance, incidence surveillance, and variant, atypical, and resistant HIV surveillance of HIV infections and AIDS in Texas; investigate reported cases as necessary to obtain required case information; and provide technical assistance to local health department contractors on surveillance activities. National HIV Behavioral Surveillance The National HIV Behavioral Surveillance project conducts behavioral surveillance activities among men who have sex with men, injecting drug users, and heterosexuals at risk in three, revolving annual phases in the Dallas-Fort Worth-Arlington Metropolitan Statistical Area (DFW MSA). These activities include conducting key informant interviews, focus groups, behavioral surveys, ethnographic analyses, and anonymous HIV testing. The project collaborates with the CDC and other national project participants to develop and implement a national research protocol, operations manual, and survey instrument. DSHS will contract with Texas A&M University Public Policy Research Institute to conduct research fi eld activities in the DFW MSA. Medical Monitoring Project The purpose of the Medical Monitoring Project is to develop a supplemental HIV/AIDS surveillance system that produces population-based estimates of characteristics of persons with HIV infection and the care they receive. By using probability sampling, estimates developed are rigorously representative of the underlying populations diagnosed with and in care for HIV infection in the project sites. Staff collects data through medical chart abstractions and patient face-to-face interviews across the state. CDC funds this project. Enhanced Perinatal Surveillance The purpose of the Enhanced HIV/AIDS Surveillance for Perinatal Prevention Project is to target and follow the progress of infants born to HIV-infected mothers toward maximal reduction of perinatal HIV transmission. Project activities include conducting medical record review of mother/infant pairs, assessing potential adverse outcomes of exposure to antiretroviral medication, matching HIV/AIDS registries to birth registries, and collaborating with CDC to track progress toward maximal reduction of perinatal HIV transmission. CDC funds this project. Contract Monitoring The HIV/STD Program is responsible for contract development and programmatic monitoring of contracts for HIV and STD prevention, STD medical care, HIV medical care and support services, ambulatory medical care, case management services, housing, administrative 13

14 services, surveillance, and related services. The program also provides programmatic technical assistance and coordinates quality management activities. The program uses a variety of tools and resources to monitor contracts. Site review tools measure compliance with an extensive scope of administrative, programmatic, quality, and planning deliverables. During site visits, the staff observes programming to the extent possible. The program provides technical assistance to ensure that contractors implement activities effectively and with fi delity and as outlined in contractual agreements. Providers must maintain policies and procedures specifi c to each activity and quality assurance plans. Site visit reports are prepared following each site visit and include fi ndings that require corrective action or improvement. Contractors are required to respond to site visit reports within a specifi ed period. DSHS staff reviews corrective action plans submitted by contractors to determine whether the response is acceptable or if further action or information is required. AA monitor medical and social services subcontractors and provide technical assistance in much the same way that DSHS monitors the AA. All AA have access to the DSHS policies, procedures, and tools used in conducting site visits. HIV/STD Program staff completed 91 site visits in Contract Type Total Visits Site visits completed in 2007 by HIV/STD Program Staff HIV Prevention Monitoring Reviews 1 Desktop Review 26 Technical Assistance Visits STD Prevention and Medical Care HIV Medical and Support Services Monitoring Reviews 1 Desktop Review 3 Technical Assistance Visits 7 Administrative Agency (AA) Monitoring Reviews 1 AA Desktop Review 2 AA Technical Assistance Visits 9 Programmatic Service Delivery Monitoring Reviews 1 Programmatic Service Delivery Technical Assistance Visits 3 Clinical AA Monitoring Reviews 1 Clinical AA Technical Assistance Visit 10 Clinical Direct Provider Monitoring and Technical Assistance Visits HOPWA 3 3 Monitoring Reviews 14

15 III EPIDEMIOLOGIC PROFILE OF HIV AND AIDS IN TEXAS Introduction This epidemiologic profi le presents a summary of information on known HIV/AIDS cases in Texas for the years 2003 to 2007 collected during routine disease surveillance. This report details cases by sex, race/ethnicity, mode of exposure and age group. It is important to consider not only the total number of cases, but also that number relative to the size of the population in question. Therefore, when possible, case rates are included to illustrate this point. A case rate is the number of people with HIV/AIDS per 100,000 members of that particular population. Comparing case rates shows the relative difference of the burden of disease across groups with different population sizes. This demonstrates how HIV/AIDS disproportionately affects different groups. Rates are not shown for groups by mode of exposure because there are no good estimates of the population size for these groups, without which a rate calculation cannot be made. The data in this report have been statistically adjusted to account for reporting delay and for delays in fi nal determination of risk groups in more recently reported cases; these adjustments are done to make trends in recently diagnosed cases more interpretable. These adjustments mean that this report will show slightly different statistics and case counts than may be found in other local or statewide surveillance reports for any one year or group. Overview In 2007 there were 62,714 people living with HIV/AIDS (PLWHA) in Texas, a 30% increase from the number of PLWHA fi ve years earlier in 2003 (48,245) (Figure 1). In each of these years, there were about 4,600 new diagnoses made, and about 1,300 PLWHA died. The increase in the number of PLWHA was not due to rises in the number of newly diagnosed cases, but because there are more new diagnoses than deaths in each year. Figure 2 shows this dynamic. From this perspective, rises in numbers of PLWHA are primarily explained by treatment successes in extending the lives of persons with HIV and AIDS. Figure 1. Number of People Living with HIV/AIDS, Texas ,000 60,000 50,000 40,000 48,245 Total 62,714 30,000 20,000 10,

16 Figure 2. Number of New Diagnoses of HIV Disease and Deaths, Texas ,000 5,000 4,000 4,612 4,784 3,000 2,000 New Cases Deaths 1, ,288 1, Characteristics of Persons Living with HIV/AIDS The numbers of living cases have increased substantially for both sexes and across all races/ ethnicities. Prevalence has also increased in every age group except those less than 13 years old (Table 1). There are about three men living with HIV/AIDS for every one woman; this sex ratio has been constant across the last fi ve years. There are more African Americans living with HIV/AIDS than any other race/ethnicity group, even though African Americans represent only 11% of the overall population. The rate of African Americans living with HIV/AIDS in 2007 was over four times the rate in Whites and about fi ve times the rate in Hispanics. Table 1. Persons Living with HIV/AIDS by Select Characteristics, Texas, 2003 and number percent rate number percent rate Total 48, , Disease Status HIV 15, , AIDS 32, , Sex Male 37, , Female 10, , Race/Ethnicity^ White 18, , African American 18, , Hispanic 11, , Other Age Group under , , , , , , , , , , Mode of Exposure* MSM 24, , IDU 8, , MSM/IDU 4, , Heterosexual 10, , Perinatal Other *Rates are not calculated because there are no good estimates of population sizes for behavioral risk groups. ^Small numbers of unknown race/ethnicity and age have been excluded. Category totals will not match. Age group refers to age in 2003 and in 2007, respectively. 16

17 Over the past fi ve years rates of PLWHA increase with age groups, (Figure 3). These data refl ect the aging of the infected population, not that new infections are increasing among older adults. This shift refl ects the continued effect of improved treatment on survival. The number of children under the age of 13 living with HIV/AIDS has decreased by 27% in since 2000, the result of highly effective treatments that prevent transmission from infected mother to child. Figure 3. Persons Living with HIV/AIDS by Age Group, Texas 2003 and 2007 Percent under Age Groups PLWHA by Race/Ethnicity While the number of living cases increased in all races/ethnicities over the past fi ve years, the increase among African Americans (31%) was substantially greater than among Whites (22%). Figure 4 shows the actual number of PLWHA on the left graph and the rate of PLWHA on the right graph. Note that while similar numbers of Whites and African Americans were living with HIV/AIDS in 2007, the rate of African American Texans living with HIV/AIDS is over four times the rate for White Texans and fi ve times the rate for Hispanic Texans. Further, the increase of the rate over the past fi ve years was sharper in African Americans (25%) than in Whites and Hispanics (both 21%). These differences demonstrate the uneven burden of disease in African Americans compared with Whites and Hispanics. 17

18 Figure 4. Number and Rate of Persons Living with HIV/AIDS by Race/Ethnicity, Texas, ,000 20,000 18,604 23,802 22,712 1, ,000 18,113 15, number 10,000 5,000 11,089 rate African American White Black Hispanic African American White Black Hispanic PLWHA by Mode of Exposure The mode of exposure is the most likely way that someone became infected with HIV based on the risks found for the case. The size of a population representing a group is necessary to determine rates of that group. Because there are no good estimates of population sizes for exposure groups, this report examines the proportion of cases due to each mode of exposure. The most common exposure groups are men who have sex with men (MSM), injection drug users (IDU), and high risk heterosexuals (Figure 5). MSM/IDU refers to cases among men who report both sex with men and injection drug use. In Texas, there is a small proportion of cases due to other causes such as transfusions and mother-to-child (perinatal) transmissions. While the number of PLWHA increased over the past fi ve years in all major exposure categories, the relative proportions of living cases for each mode of exposure did not change substantially. In 2007, MSM accounted for half of the people living with HIV/AIDS. The proportion of persons living with HIV/AIDS who were exposed through heterosexual sex increased from 22% in 2003 to 24% in 2007; the proportion of IDU and MSM/IDU cases each dropped about one percentage point. 18

19 Figure 5. Persons Living with HIV/AIDS by Mode of Exposure, Texas, 2007 Hetero 24% Perinatal 1% Other 1% MSM/IDU 7% MSM 51% ID U 16% New Diagnoses of HIV/AIDS The data described here represent these newly diagnosed cases in a given calendar year. They do not include new AIDS diagnoses for cases previously known to be HIV positive. Table 2 shows selected characteristics for newly diagnosed cases from From 2003 to 2007, the number of new diagnoses remained fairly stable for both sexes, with about a 3:1 ratio of males to females that has remained constant over the years. African Americans had both the highest number and rate of new diagnoses every year. The 2007 rate of new cases in African Americans was almost seven times higher than the rate in Whites and almost fi ve times higher than the rate in Hispanics. MSM made up the largest proportion of new diagnoses every year, with an average of 2,369 cases per year. The number and proportion of IDU-related cases appears to have declined slightly over the 5-year period. Over the fi ve years, the number and rate of new diagnoses among those aged years show a slow, steady increase, while those aged years show a gradual decrease from 1,654 new cases with a rate of 49.3 to 1,400 new cases with a rate of

20 Table 2. New HIV/AIDS Diagnoses by Select Characteristics, Texas number rate number rate number rate number rate number rate Total 4, , , , , Sex Male 3, , , , , Female 1, , , , Race/Ethnicity^ White 1, , , , , African American 1, , , , , Hispanic 1, , , , , Other Age Group under , , , , , , , , , , Mode of Exposure* number % number % number % number % number % MSM 2, , , , , IDU MSM/IDU Heterosexual 1, , , , , Perinatal Other *Rates are not calculated because there are no good estimates of population sizes for behavioral risk groups. ^Small numbers of unknown race/ethnicity and age have been excluded. Category totals will not match. Age group refers to age in 2003 and in 2007, respectively New Diagnoses by Race/Ethnicity Examining Males and Females Separately Separating newly diagnosed cases by race/ethnicity shows important differences in sex ratios and rates and more clearly illustrates the tremendous burden of disease within the African American community (Table 3). While the ratio of male-to-female cases among Whites and Hispanics is about 5:1, the male-to-female ratio is only 2:1 in African Americans. Comparisons of sex and race/ethnicity demonstrate that African American males had a rate 4 to 5 times higher than other male rates. Further, the difference of the rate in African American women is even more striking: not only was the rate in African American females 8 to 16 times higher than rates in Hispanic and White women, respectively, it was over twice the rate in White and Hispanic men (Table 3 and Figure 6). 20

21 Table 3. Number and Rate of New Diagnoses by Sex and Race/Ethnicity, Texas ,600 1,400 1,200 1,000 Male Female Number Rate Number Rate White 1, African American 1, Hispanic 1, Other Figure 6. Comparison of Count and Rate of New HIV Diagnosis by Race/Ethnicity, Texas ,091 1,359 1, number White African American Black Hispanic male female rate White African American Black Hispanic male female 2007 New Diagnoses by Sex by Age Group Since HIV generally has a long asymptomatic incubation period, the age at infection may be several years earlier than the age at diagnosis. The average age at diagnosis has increased from 29 in 1992 to 37 in Males had a higher rate of new diagnoses than did females in every age group. The highest rate for males was in 35 to 44 year olds (104.1 per 100,000) and for females was in the year olds (29.9 per 100,000) New Diagnoses by Sex, Race/Ethnicity, and Mode of Exposure The examination of mode of exposure, sex, and race/ethnicity reveals additional differences. Among White males, the overwhelming majority were in the MSM mode of exposure category, with just over 8% in the IDU and 7% in the MSM/IDU categories and about 5% in the heterosexual category (Table 4). Hispanic male cases also had MSM as the main mode of exposure, but higher proportions of heterosexual and IDU transmissions. While the majority of African American males diagnosed in 2007 were MSM cases, the proportion was much lower than that seen in White and Hispanic males, and African American men had higher proportions 21

22 of heterosexual and IDU cases. In women, IDU exposures make up a much greater proportion of cases in White women compared to African American and Hispanic women, with the latter two groups showing a much greater proportion of heterosexual exposures. Table 4. New HIV/AIDS Diagnoses by Sex, Mode of Exposure, and Race/Ethnicity, Texas 2007 Male Female White African American Hispanic Other number % number % number % number % MSM IDU MSM/IDU Heterosexual Perinatal Other IDU Heterosexual Perinatal Other Concurrent HIV/AIDS Diagnosis Despite the long latency period of HIV progression to AIDS, many people received both an HIV diagnosis and an AIDS diagnosis within a short time frame. This is a late diagnosis of HIV - meaning they have been living with HIV for years before being diagnosed. Since HIV is communicable, this late testing represents a lost opportunity for early treatment and for education about effectively preventing transmission to others. From 2003 through 2007, over one quarter of all new diagnoses in Texas received an AIDS diagnosis within one month of their HIV diagnosis. Further, over one third of all new diagnoses received HIV and AIDS diagnoses within one year (Figure 7 and Table 5). 1 These numbers show that a substantial proportion of PLWHA were not diagnosed until late in the progression of HIV disease. A larger proportion of males than females received HIV and AIDS diagnosis within one month and within one year. Nearly one third of diagnoses among Hispanics had both diagnoses within one month compared to 24% and 23% of diagnoses among Whites and African Americans, respectively. This disparity was maintained at the one-year mark. Of the major risk categories, the difference in proportion was negligible at one month and one year. A higher percentage of cases with concurrent diagnoses was found in the 55+ age group. 1. The number and proportion of those with diagnoses within one year include those with diagnoses within one month. 22

23 Total Male Female White African American Hispanic Other < and up IDU MSM/IDU Hetero MSM Perinatal Other (35.4 Total) (36.4 Total) (32.1 Total) (31.9 Total) (32.8 Total) (43.0 Total) (33.3 Total) (9.3 Total) w /i 1 month 2.5/ 0.0 (2.5 Total) w /i 1 year (20.0 Total) (31.0 Total) / 1.3 (4.0 Total) 10.0 (39.6 Total) 10.5 (43.3 Total) 11.3 (52.1 Total) 9.7 (34.5 Total) 10.7 (35.8 Total) 9.7 (36.4 Total) 8.9 (35.2 Total) (50.3 Total) Percent Figure 7. Persons Diagnosed with HIV and AIDS within One Month or One Year, Texas * Table 5. Selected Characteristics of Persons Diagnosed with HIV and AIDS within One Month or One Year, Texas Diagnosed within One Month Diagnosed within One Year number % number % Total 6, , Male 4, , Female 1, , White 1, , African American 2, , Hispanic 2, , Other under , , , , , , and up MSM 3, , IDU , MSM/IDU Heterosexual 1, , Perinatal Other *The sum total for each category may not match the total due to rounding of the data. 23

24 2007 PLWHA by Geographic Area Geographic comparisons are based on residence at the time of the most recent diagnosis, not current residence. Non-AIDS cases are attributed to the county of residence at HIV diagnosis and AIDS cases are attributed to the county of residence at the time of AIDS diagnosis. The Austin, Dallas, Fort Worth, Houston, and San Antonio areas have been broken out separately because of their high numbers of living and new cases (Figure 8). These fi ve areas meet the federal criteria for direct funding from the Health Resources and Services Administration for HIV care and treatment; they have been designated as Eligible Metropolitan Areas (EMA) or Transitional Grant Areas (TGA) depending on the number of HIV/AIDS cases in their area. Outside of the EMA/TGAs, the areas along the US-Mexico border and across East Texas are of special interest. For this report, we defi ne the border area as those 32 counties within 100 kilometers of the US-Mexico border, a standard defi nition in health and human services reports. The East Texas area includes all counties in Public Health Regions 4, 5, and 6, excluding the Houston EMA counties and Henderson County, which is included in the Dallas EMA. Figure 8. Geographic Areas of Interest PLWHA were concentrated in metropolitan areas, particularly Houston and Dallas -- over half of PLWHA were in the Dallas and Houston areas (Figure 9). The Austin, Forth Worth, and San Antonio TGA each had about 4,100 PLWHA. The numbers of PLWHA in the other comparison groups (Border, East Texas, and the remainder of Texas) each had around 3,700 PLWHA. Additionally, just over 6% of all PLWHA in Texas in 2007 were diagnosed in the Texas Department of Criminal Justice (TDCJ) system. These cases were not attributed to a geographic area as TDCJ remains the residence at diagnosis even once the prisoner is released. This artifi cially infl ates the numbers for TDCJ by counting more cases in the system than actually reside there. As a result, TDCJ cases reported here do not refl ect the number of cases currently in TDCJ, and so prevalence rates for TDCJ are not included here. 24

25 Figure 9. Proportion of Persons Living with HIV/AIDS by Area, Texas 2007 U.S.-Mexico Border 5.5% East Texas 6.0% Other 6.5% TDCJ 6.2% Austin TGA 6.6% Dallas EMA 24.5% San Antonio TGA 7.0% Fort W orth TGA 6.5% Houston EMA 31.1% Rates of living cases were uniformly higher in the EMA/TGA compared to the non-ema/tga (Figure 10). The highest rates were in the Dallas (369.4 per 100,000) and Houston (401.9 per 100,000) areas. Figure 10. Rate of Persons Living with HIV/AIDS by Geographic Area, Texas, Rate of PLWHA Houston EMA Dallas EMA Austin TGA San Antonio TGA Fort Worth TGA East Texas U.S.-Mexico Border Other Table 6 shows the number and rate of persons living with HIV/AIDS for the EMA/TGA, the US- Mexico border, East Texas, and the remainder of Texas. In all areas, cases and rates for males were substantially higher than those for females. Compared to other areas, the proportion of females was elevated in East Texas (32%), Houston (27%), and Fort Worth (24%). 25

26 Table 6. Persons Living with HIV/AIDS, Select Characteristics by Area, Texas 2007 Statewide Austin TGA Dallas EMA Fort Worth TGA Houston EMA San Antonio TGA East Texas U.S.-Mexico Border # rate # rate # rate # rate # rate # rate # rate # rate Total 62, , , , , , , , Disease Status HIV 26, , , , , , , , AIDS 36, , , , , , , , Sex Male 49, , , , , , , , Female 13, , , , Race/Ethnicity White 22, , , , , , , African American 23, , , , ,508 1, , Hispanic 15, , , , , , Other Age Group < , , , , , , , , , , , , , , , , , , , , , , , Mode of Exposure % % % % % % % % MSM 32, , , , , , , , IDU 9, , , MSM/IDU 4, , Heterosexual 15, , , , Perinatal Other Other

27 The racial/ethnic profi les of PLWHA varied across the different areas of Texas. Depending on the area of the state, the rates for African Americans were two to fi ve times higher than the rates for Whites or Hispanics. In the Houston and East Texas areas, the largest numbers of living cases were among African Americans; in the San Antonio and US-Mexico border areas, the largest numbers of cases were in Hispanics; and in all other areas, the largest numbers of PLWHA were among Whites. Across all EMA/TGA areas, the rates for African Americans were substantially higher than Whites and Hispanics. The rate for African Americans in the Houston area was 1,186 PLWHA per 100,000 population. In other words, one in 83 African Americans in the Houston area was living with HIV/AIDS in Further, one in 101 African Americans in Dallas and one in 116 African Americans in the Austin area were PLWHA. In Austin, Dallas, Fort Worth, and Houston, the rates for Whites exceeded Hispanic rates; in San Antonio, the Hispanic rate was higher than that for Whites. Outside of these areas, the rates for Hispanics were comparable to those for Whites, but still much lower than the rates for African Americans. In terms of mode of exposure, MSM were consistently the largest proportion of cases across the state; except for TDCJ, where the majority of cases were IDU. In the Austin, Dallas, San Antonio, and border areas, MSM made up more than half of living cases. Two thirds of PLWHA in the Dallas area were MSM. In Houston and East Texas, heterosexual cases made up a more substantial proportion of PLWHA (almost one third). The Fort Worth TGA was the geographic area with the largest proportion of IDU cases at 20%. Subpopulations with Prevalence Greater Than 1% The examination of high morbidity demographic subpopulations (i.e. looking at sex, race/ ethnicity, and age groups simultaneously) within geographic areas revealed startling fi gures. Many subpopulations in the EMA/TGA had PLWHA prevalence rates above 1,000 per 100,000 population; or 1% of the sub-population (Table 7). Overall, one in 378 people in the Texas population was living with HIV/AIDS in Texas in African American males aged and had the highest prevalence rates in every area. Of African American males aged 35-44, one in 27 in Houston and one in 32 in Dallas were living with HIV/AIDS. Of African American males aged 45-54, one in 36 in Austin, one in 36 in Dallas, and one in 31 in Houston were living with HIV/AIDS. In most areas, White male subpopulations had the greatest numbers of people living with HIV/AIDS, but in San Antonio, Hispanic males aged made up the largest subpopulation. In Houston, the numbers of African American males were comparable to the numbers of White males. 27

28 Table 7. Subpopulations of PLWHA Prevalence Greater than One Percent, Texas 2007 Area Race/Ethnicity Sex Age One in: Male Male Austin EMA African American Male Male Female Female White Male Male Female Dallas EMA Female African American Male Male Male East Texas African American Male Male Male Fort Worth EMA African American Male Male White Male Male Female Female Houston EMA Female African American Male Male Male Male San Antonio EMA African American Male Male Hispanic Male Male U.S.-Mexico Border African American Male

29 IV EPIDEMIOLOGIC SUMMARY OF STD IN TEXAS Syphilis Syphilis is an STD caused by the spirochete Treponema pallidum. Primary and secondary (P&S) syphilis, the acute form of the disease, is characterized by primary lesions (an ulcer or chancre at the site of infection) followed by secondary infection (manifestations that include rash, mucocutaneous lesions, and adenopathy). Untreated P&S syphilis progresses into a chronic disease with long periods of latency. Statewide, 1,172 cases of P&S syphilis were reported in 2007, a 10% increase from 1,066 cases reported in 2006 and the seventh straight year of rising case reports (Figure 11). The largest P&S syphilis increases in Texas were seen in Harris, Jefferson and Bexar Counties in Dallas County showed the most notable decrease in P&S case numbers compared to Figure 11. Primary and Secondary Syphilis Cases: Texas, ,000 6,000 5,000 4,000 3,000 2,000 1,000 Cases Year Year The overall state rate for P&S syphilis in 2007 was 4.9 cases per 100,000 population. Men accounted for 74% of reported cases, down slightly from 75% in The age distribution of P&S syphilis cases was divided fairly evenly across the three age groups of most common occurrence; 15 to 24 (29%), 25 to 34 (29%), and 35 to 44 (24%) years of age. African Americans continued to account for the largest proportion (52%) of P&S syphilis cases reported in Texas in 2007; the rate of P&S syphilis among African Americans was 22.7 cases per 100,000 population. Although the P&S syphilis rate among African Americans has decreased by 57% since 1995, it remained disproportionately high compared with rates for Hispanics (3.1 per 100,000) and Whites (2.4 per 100,000) in 2007 (Figure 12). Among African American women, those aged 15 to 24 had the highest rate at 41.8 cases per 100,000 population. The highest rate for African American men was found among an older age group, those aged 25 to 34, at 60.3 cases per 100,

30 Figure 12. Primary and Secondary Syphilis Case Rates by Race/Ethnicity: Texas, 2007 Cases per 100,000 Population African American Hispanic White Other Total Race/Ethnicity Year Latent syphilis is defi ned as those periods after infection with Treponema pallidum when patients present no symptoms of disease. Patients who have latent syphilis and who acquired syphilis within the preceding year are classifi ed as having early latent syphilis; untreated cases of more than one year s duration are classifi ed as late latent. Tertiary syphilis is the symptomatic late-stage of the disease that may include neurologic and cardiovascular sequelae. The late latent and tertiary stages of syphilis were contracted many years prior to the cases being diagnosed and reported, and syphilis is not as likely to be transmitted in the late stages, thus, there are limited public health implications to these diagnoses. African Americans continue to account for the largest proportion of syphilis cases reported in Texas. Like P&S syphilis, the decreases in early latent syphilis seen in the 1990s have been replaced with increases in recent years. The total number of early latent syphilis cases in 2007 was 1,562, up 17% from 1,334 cases in The overall rate of early latent syphilis in 2007 was 6.5 cases per 100,000 population (Figure 13). The incidence rate for early latent syphilis among African Americans was 28.7 cases per 100,000, compared to 4.6 among Hispanics and 2.9 among Whites. Congenital syphilis, one of the most serious forms of the disease, can cause abortion, stillbirth, premature delivery, or may lead to other severe complications in the newborn. In 2007, 95 cases of congenital syphilis were reported, up from the 84 cases reported in Harris County continues to report the most congenital syphilis, with 39 cases in 2007, followed by Dallas County with 22 and Tarrant County with seven. Statewide, 52% of congenital cases were among African Americans, 39% among Hispanics and 5% among Whites. Based on 2004 live birth numbers (more recent data was unavailable), the estimated rate of congenital syphilis in 2007 was 24.9 cases per 100,000 live births, up from 22.3 per 100,000 in

31 Figure 13. Syphilis Case Rates: Texas, Cases per 100,000 Population Total Syphilis Early Latent Syphilis P&S Syphilis Year Total syphilis refers to all reported syphilis cases regardless of the disease stage, which includes congenital, P&S, early latent, late latent and tertiary syphilis. In 2007, over 5,570 cases of total syphilis were reported, up 12% from 4,961 cases reported in 2006, for a statewide rate of 23.3 cases per 100,000 population. Chlamydia The microorganism Chlamydia trachomatis is the most common cause of reportable sexually transmitted infections in Texas. Reports of chlamydia in 2007 totaled 84,784, up from 75,319 cases in 2006 (Figure 14). Of the total chlamydia cases reported, 79% were among women. Because of the increased risk of severe outcomes among women, including the potential for pelvic infl ammatory disease, ectopic pregnancy, and the possibility of infecting a newborn child, chlamydia screening programs almost always focus on women and thus, men are less likely to be tested and diagnosed. Women are frequently screened for chlamydia during clinical exams for family planning, prenatal care, and routine Pap smear testing. Since this infection is often asymptomatic, chlamydia case reports are largely dependent upon the volume of screenings being conducted, more so than gonorrhea, for example. Given that men are rarely screened for chlamydia, the disease incidence among men is diffi cult to gauge. The 2007 chlamydia case rate for women was 562 cases per 100,000 population; with African American women having the highest rate (1,339 per 100,000), followed by Hispanic and White women (633 and 228 per 100,000, respectively) (Figure 15). Men showed a similar racial/ethnic distribution to women but with far lower rates. Seventy-two percent of all reported chlamydia patients (over 60,000 cases) were 15 to 24 years of age. The chlamydia rate among women aged 15 to 24 was 2,848 cases per 100,000 population. African American women account for the largest proportion of chlamydia cases reported in Texas. 31

32 Cases 90,000 80,000 70,000 60,000 50,000 40,000 30,000 20,000 10,000 Figure 14. Chlamydia Cases: Texas, Year Figure 15. Chlamydia Case Rates Among Women by Race/Ethnicity*: Texas, Cases per 100,000 Population 1,400 1,200 African American Hispanic White Total 1, Year * Excludes cases of unspecifi ed race/ethnicity. Gonorrhea The bacteria Neisseria gonorrhoeae causes gonorrhea, the second most frequently reported STD in Texas. Left untreated, gonorrhea may lead to sterility in men and pelvic infl ammatory disease, ectopic pregnancy, and sterility in women. The number of gonorrhea case reports increased from 30,270 in 2006 to 31,761 in 2007 (Figure 16). The Texas gonorrhea rate was 133 cases per 100,000 population in 2007, up from 129 per 100,000 in The rate among women in 2007 (134 per 100,000) was only slightly higher than the rate for men (131 per 100,000). 32

33 100,000 Cases Figure 16. Gonorrhea Cases: Texas, ,000 60,000 40,000 20, Year The gonorrhea rate for African Americans (626 cases per 100,000) was over eight times higher than the rate for Hispanics (71 per 100,000) and over 14 times higher than the rate for Whites (42 per 100,000) (Figure 17). African American men had the highest rate of all race/ethnicity-sex groups at 691 cases per 100,000 population. Gonorrhea cases among African Americans aged 15 to 24 accounted for the greatest share of African American cases (62% of those reported); they also represented 33% of all cases reported regardless of race/ethnicity or age. African Americans have the highest rate of gonorrhea infection in Texas. Cases per 100,000 Population 1,750 1,500 African American Hispanic White Total Figure 17. Gonorrhea Case Rates by Race/Ethnicity*: Texas, ,250 1, Year * Excludes cases of unspecifi ed race/ethnicity. Among age groups, the highest rates were among those aged 15 to 24 (526 per 100,000) followed by those aged 25 to 34 (225 per 100,000). Women aged 15 to 24 comprised 70% of all female cases; young men in this age group accounted for 50% of all male gonorrhea cases. 33

34 V. HIV PREVENTION SERVICES The DSHS HIV/STD Program provides a variety of HIV prevention services across the state through contracts with local health departments and community-based organizations. DSHS staff provides technical assistance and monitors contractors to ensure compliance with objectives and approved use of program funds, and maintains data systems that collect important information for the evaluation and reporting of prevention activities. A total of 39,232 clients (duplicated count) participated in individual-level, group-level, and community-level HIV behavioral interventions provided by DSHS HIV prevention contractors in 2007 (Table 8). Table 8. Participation in Funded HIV Prevention Interventions, 2007 Intervention Type Individual-Level Interventions Participants Individual Level Intervention 33,807 Group Level Intervention 5,117 Community Level Intervention 308 Total 39,232 Individual-level HIV behavioral interventions provide information, training, or support through a personal interaction with a trained prevention worker. These interventions, delivered to one person at a time, seek to modify knowledge, attitudes, beliefs, self-effi cacy, and emotional wellbeing, and are intended to reduce risk-taking behaviors. They can involve individualized risk reduction counseling delivered by a trained counselor, educator, peer or other professional. 1 Counseling, testing, and referral and comprehensive risk counseling and services are individual level interventions funded by the DSHS HIV/STD Program. Counseling, Testing and Referral (CTR) is a set of interventions designed to inform clients of their HIV status, encourage behavior change that reduces risk, and link clients to appropriate services. HIV/STD Program contractors use an evidence-based protocol as a tool to guide CTR delivery. Table 9 summarizes the counseling and testing data for 2007 by sex and race/ethnicity. Table 10 summarizes the counseling and testing data by sex and reported risk behavior. Please note 1. Individual-, Group-, and Community-Level HIV Behavioral Interventions are Recommended to Reduce Risk of Sexually-Acquired HIV in Adult Men Who Have Sex with Men. Guide to Community Preventive Services Website. Centers for Disease Control and Prevention. Created: 05/14/2007. Accessed on: 9/21/08. 34

35 that these data and the following discussion represent the number of clients tested and do not necessarily refl ect the characteristics of all persons living with HIV/AIDS in Texas. Instead, these data refl ect the clients accessing CTR services. Please see epidemiologic data in the Section III of this report for information on newly diagnosed cases and people living with HIV/ AIDS. Table 9. Counseling, Testing and Referral: Tests and Positives by Sex and Race/Ethnicity, 2007* Male Female Race/Ethnicity Total Tested Percent Positive Percent Total Tested Percent Positive Percent White 5, , African American 5, , Hispanic 7, , Other Total 18, , *City of Houston CTR data is reported directly to CDC and is not included in this report. Table 10. Counseling, Testing and Referral: Tests and Positives by Sex and Risk Behavior, 2007* Male Female HIV exposure hierarchy Total Tested Percent Positive Percent Total Tested Percent Positive Percent MSM/IDU MSM 4, IDU 2, , Hetero 11, , Non-targeted Total 18, , * City of Houston CTR data is reported directly to CDC and is not included in this report. In 2007, DSHS contractors reported 32,800 HIV tests. Men made up 57 percent of the clients testing for HIV; testing clients were almost equally divided between White (30%), African American (32%), and Hispanic (36%). Clients with risks associated with heterosexual sex made up the largest group of clients (70%), while men who have sex with men (MSM) and injection drug users (IDU) made up 12 percent and 16 percent of the clients testing, respectively. Of tests performed, 1.5 percent was positive. This rate is up from the previous year (1.22 per 100). The programs positivity rate is five times higher than the overall rate of living cases (0.26 persons living with HIV per 100 Texans), which indicates the degree to which these programs successfully target persons at highest risk of becoming HIV infected. Positivity rates were over two times higher for men compared to women (2.0 per 100 for men and 0.9 per 100 for women). Among women, African American women had the highest positivity rate (1.3 per 100), a rate two times higher than White or Hispanic women. The positivity rate in White men was 1.4 per 100 tests; while the positivity rates were greater in 35

36 African American men and Hispanic men (2.6 per 100 and 2.0 per 100, respectively). This breakdown of positive test results, particularly in men, is different from that of the epidemic itself in that it does not completely refl ect the disproportionate burden of disease between the racial/ethnic groups. Surveillance data show that the rate of newly diagnosed African Americans is fi ve and four times higher than Whites and Hispanics, respectively. Across risk groups, MSM and men who both had sex with men and used injection drugs (MSM/ IDU) risk groups had positivity rates of 4.8 and 5.7, respectively. These are about six times higher than the IDU (0.6 per 100) or heterosexual (0.9 per 100) risk groups. Comprehensive Risk Counseling Services (CRCS) is extended HIV prevention counseling with the goal of promoting the adoption and maintenance of HIV risk reduction behaviors for clients with multiple, complex problems and risk reduction needs. It is intended for clients who have diffi culty initiating or sustaining practices that reduce or prevent HIV acquisition, transmission, or re-infection and combines risk reduction counseling and traditional case management to provide ongoing, individualized prevention counseling, support, and service referrals. A total of 958 clients were served by CRCS in Group-Level Interventions Group-level HIV behavioral interventions are designed to infl uence individual risk behavior by changing knowledge, attitudes, beliefs, and self-effi cacy in a small group setting. These interventions promote individual behavior change in situations where information and activities delivered by a trained counselor, educator, or other facilitator can be reinforced by peer pressure and support from other group members. The interventions often focus on the development of skills through live demonstrations, role plays, or practice. Skills may include learning how to use condoms correctly, how to implement personal decisions to reduce risk, and how to negotiate safer behaviors effectively with partners. 1 The DSHS HIV/STD Program funds a variety of scientifi cally proven curriculum-based group level interventions for persons at high risk for HIV acquisition or transmission. A total of 5,117 clients completed group-level interventions in Community-Level Interventions Community-level HIV behavioral interventions are designed to infl uence individual risk behavior by changing knowledge, attitudes, and beliefs in a defi ned community. While the typical defi nition of community has geographic connotations, the communities targeted by these interventions are communities of persons at highest risk of HIV, such as the gay community, or the community of injection drug users. These interventions can motivate and reinforce behavior change in individuals who do not participate directly in the intervention by using peer advocates to promote norms of safer sex and risk reduction - through the infl uence of popular opinion leaders, community mobilization, or social networks. The interventions may have several components, requiring complex coordination and implementation. 1 The DSHS HIV/STD Program funds several scientifi cally proven community level interventions for persons 36

37 at high risk for HIV acquisition or transmission. A total of 308 clients completed training to act as peer-advocates in community-level interventions in HIV Perinatal Prevention The HIV/STD Program initiated an HIV perinatal workgroup in December The workgroup is led by the HIV/STD Epidemiology and Surveillance Branch and includes representation from other health department entities, including the HIV/STD Comprehensive Services Branch, DSHS regional offi ces, the Family Health Research and Program Development Unit, the Community Mental Health and Substance Abuse Services Section, and the Disease Prevention and Intervention Section/Data and Services Coordination Group. The workgroup agreed to target fi ve areas related to the reduction and prevention of HIV perinatal transmission: Leadership Standards of care Advocacy Education Outreach Within DSHS, HIV/STD Epidemiology and Surveillance, Maternal and Child Health, Infectious Disease, Viral Hepatitis, and HIV/STD Comprehensive Services staff collaborated on projects for HIV perinatal prevention in The HIV/STD program provided intensive guidance, review, and training on CDC s Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings. The program has continued to share the HIV perinatal prevention booklets targeting African American and Hispanic women with other DSHS programs. DSHS also provided technical assistance to other DSHS programs on Texas laws governing HIV testing of pregnant women. In 2007, the HIV/STD program met with the Hepatitis B Case Management Program to review protocols, reporting practices, and target populations. HIV/STD staff presented on HIV perinatal transmission prevention issues at the statewide HBV conference. Staff from the HIV/STD Comprehensive Services Branch and the HIV/STD Epidemiology and Surveillance Branch worked closely in 2007 sharing data, trends, and client information to assure that cases were entered correctly into the enhanced perinatal surveillance (EPS) database. In preparation for the competitive HIV Perinatal Prevention request for proposals, EPS staff provided data to guide the program in identifying the geographic areas of residence of exposed infants in the state. In 2007, DSHS began a contract with the Harris County Hospital District (HCHD) to implement rapid HIV testing in 10 labor and delivery sites in Houston by educating hospital staff about the rationale and merits of rapid testing during labor and delivery, training them on the rapid testing protocol, and providing support and technical assistance as needed. HCHD provided trainings 37

38 to 273 administrators and clinicians in all 10 hospitals. By the end of 2007, six of the hospitals had amended their standing orders to include rapid testing of women who present at labor and delivery without a current HIV test on fi le. The lesson learned from the fi rst year of this project is that each facility needs to have the explicit statement, Rapid HIV test for any woman with no prenatal care or with undocumented HIV status in the admission orders for the implementation of rapid testing to be routine for this particular target population. DSHS received data from two hospitals, Ben Taub General Hospital (Ben Taub) and Lyndon B. Johnson General Hospital (LBJ). The following tables summarize data gathered from the two hospitals. As can be seen in Table 11, Ben Taub Results, signifi cantly higher percentages of women who had no prenatal care received a rapid HIV test across all three time periods. Thirty-fi ve percent (n=68, p=0.0001) of women at Time 2 received a rapid HIV test, compared to only 7.4 percent at Time 1. At Time 3, 51.2 percent (n=86, p=0.0489) of women with no prenatal care received a rapid HIV test compared to 35.3 percent at Time 2. According to evaluation data from the program evaluator, Dr. Jessica Davila of Baylor College of Medicine, there was an overall signifi cant increase over time (p<0.0001) in the number of women who received a rapid HIV test among those who received no prenatal care across the three time periods at Ben Taub. Table 11. Ben Taub Results of Rapid HIV Testing Protocol Initiative at Labor and Delivery Sites (Intervention Performed in June 2007) Mar-May 2007 Jul-Sept 2007 Oct-Dec 2007 Total number of deliveries Unknown (~1445) Number of women with no prenatal care 68 (4.8%) 68 (4.6%) 86 (~ 5.9%) Number of women who received a rapid HIV test among those with no prenatal care Number of women who did not receive a rapid HIV test but received a standard HIV test among those with no prenatal care Number of women with no prenatal care who did not receive any HIV test 5 (7.4%) 24 (35.3%) a 44 (51.2%) b,c 56 (82.4%) 37 (54.4%) 37 (43.0%) 7 (10.3%) 7 (10.3%) 5 (5.8%) a Increase in testing from Time 1 to Time 2 (p=0.0001) b Increase in testing from Time 1 to Time 3 (p=0.0001) c Increase in testing from Time 2 to Time 3 (p=0.0489) 38

39 Table 12. LBJ Results of Rapid HIV Testing Protocol Initiative at Labor and Delivery Sites (Intervention Performed in July 2007) Apr-Jun 2007 Aug-Sept 2007 Oct-Dec 2007 Total number of deliveries Unknown Unknown Unknown Total number with no prenatal care Number of women who received a rapid HIV test among those with no prenatal care Number of women who did not receive a rapid HIV test but received a standard HIV test among those with no prenatal care Number of women with no prenatal care who did not receive any HIV test a Increase in testing from Time 1 to Time 2 (p=0.0159) 34 (27.4%) 59 (41.5%) a 38 (35.2%) 85 (68.5%) 81 (57.0%) 63 (58.3%) 5 (4.0%) 2 (1.4%) 7 (6.5%) In addition to the rapid testing protocol initiative, the HCHD was also charged with hosting and coordinating the Houston Perinatal Task Force Group. This group grew throughout the year to include participants from the ten hospitals where the protocol was being implemented. In addition, participants included staff from the City of Houston STD/HIV and Enhanced Perinatal Program, as well as other signifi cant Houston HIV Perinatal Transmission Prevention stakeholders. The group met four times in 2007 and addressed broad topics such as evidencebased interventions for women of child bearing age, perinatal case management for HIV positive women, the rapid testing protocol, routine testing in medical settings, the Houston syphilis health alert, and standards of care for pregnant women living with HIV. In 2007, DSHS continued its HIV Perinatal Prevention Transmission contracts with three community-based organizations in East Texas. The programs continued to focus their efforts on providing the majority of their services to women who are HIV positive and pregnant. The programs provided specialized case management services to 25 HIV positive pregnant women. Of those 25 women, 23 received prenatal antiretroviral therapy (ART), one terminated the pregnancy, and one miscarried. Sixteen of the 25 case managed women delivered during the contract year. Of the 16 who delivered, all received prenatal ART and intrapartum ART and all infants received oral zidovudine (AZT). There has not been one single report of mother-to-child transmission among the delivered infants. Of all HIV positive pregnant women who participated in the HIV Perinatal Prevention Program in 2007, there was not one single report of mother-to- child HIV transmission among the delivered infants. 39

40 Case managers from the contracted programs worked closely with the women and their medical providers in 2007 to address issues related to side effects of and adherence to HIV medications. They also provided assistance with prenatal care appointments. Programs reported working closely with their internal outreach staff and the HIV public health follow-up teams to assure that women have received their HIV positive test results and accessed prenatal and HIV care. Disease Intervention Specialists (DIS) are assigned to deliver test results to women with no result on fi le and fi nd those who fail to show up for prenatal appointments by either referring or taking them to care. Each of the contracted programs supported provider trainings and media campaigns in The programs facilitated 15 events for 588 clinicians, which included two day-long conferences, lunches, dinners, and in-service events. The training topics included HIV and women s health issues, the perinatal treatment protocol, adherence to medications, social and psychological issues, co-infection, rapid testing, and testing laws. The media campaigns included newspaper articles on the importance of pregnant women receiving prenatal care and knowing their HIV status, radio and television interviews, distribution of education materials, and a women s speakers bureau. The greatest accomplishments regarding perinatal transmission prevention during 2007 were the fi rst year success of the program to implement rapid testing in labor and delivery sites and the continued efforts of the perinatal specialized case management programs. It has been, and continues to be, invigorating to see AIDS services organizations that do not have additional resources (Ryan White Part D funds, for example) integrate HIV perinatal transmission prevention activities into the general framework of their overall programs. Through the years, these programs have developed a specialized service for HIV positive women and have established resources and collaborations with HIV and obstetric care providers. DSHS continues to see signifi cant decreases in perinatally acquired HIV and an increase of HIV positive pregnant women on all three arms of ART therapy. From 2000 to 2006, the number of women of childbearing age living with HIV/AIDS increased by 59.5 percent, and yet the number of cases of perinatally transmitted HIV decreased by 72 percent in the same period. However, DSHS remains concerned about the nine case reports of mother-to-infant HIV transmission in From chart abstraction data, it appears that of the women delivering infected infants, 11 percent were diagnosed as HIV positive at delivery, 33 percent received inadequate prenatal care, and 44 percent did not receive the recommended three-part antiretroviral therapy. DSHS is hopeful that the increased adoption of rapid testing in labor and delivery sites will increase the number of HIV positive women and infants at risk of infection who receive ART during and after delivery. In addition, the Houston and statewide perinatal work groups are working to increase awareness among care providers, the community, and stakeholders regarding the importance of timely prenatal care and HIV testing for all women. 40

41 HIV Prevention Planning, 2007 DSHS made the decision in late 2006 to transition community planning activities from six regional Community Planning Groups (CPGs) to one statewide CPG. To facilitate this change, DSHS convened a transition team composed of co-chairs from the six regional CPGs and DSHS staff. This transition team developed a scope of work that included timelines, activities, goals, and objectives for the new statewide CPG. The team also developed membership recruitment and retention strategies and tools and made recommendations for statewide CPG membership criteria. The team solicited membership applications from December 2006 through March Criteria for member selection for the fi rst term of the statewide CPG were: Experience with community planning Expertise and/or experience providing HIV/STD prevention services Membership in or representation of a priority population listed in current comprehensive plans Institutional memory and insight with HIV/STD policy matters in Texas The fi rst meeting of the statewide Texas HIV/STD Prevention Community Planning Group (TXCPG) was in May 2007 in Dallas. New statewide CPG members received an in-depth orientation of the new CPG structure, anticipated roles and responsibilities, and future planned activities. The TXCPG met two additional times in Dallas in During these meetings, the TXCPG developed their committee structure, defi ned their roles and responsibilities based on current CDC and DSHS guidance, selected leadership from within their members, and developed preliminary work plans and timelines for fi scal year The TXCPG also selected African American men who have sex with men and African American women in East Texas for assessment based on data collected from previous assessments, key informant data, and epidemiologic data. DSHS staff provided technical assistance and training on CDC community planning guidance by the Southwest Centers for Application of Prevention Technologies on HIV Prevention Programs, funded through the Substance Abuse/Mental Health Services Administration in Texas. The Texas Education Agency presented How Issues Get to the Classroom. DSHS completed a preliminary prevention services resource inventory listing all prevention resources available in Texas. DSHS will complete the inventory in 2008 once the CDC awards direct funds and the City of Houston awards their contracts for prevention services. DSHS participated in a baseline data work group for the Bexar County Harm Reduction Work Group as part of the syringe exchange pilot project authorized the Texas Legislature. This work group consisted of subject matter experts enlisted to assist the pilot project in conducting a 41

42 community assessment to determine where to focus the efforts of the project. DSHS provided data to the Bexar County Harm Reduction Work Group, which was compiled in a report entitled IDU-Related HIV Tests and HIV Disease in Bexar County, HIV/AIDS surveillance data, testing and counseling data, and limited data on diabetes and viral hepatitis were included. HIV Prevention Contracts and Monitoring, 2007 In spring 2007, DSHS released its competitive HIV prevention request for proposals for counseling, testing, and referral and health education and risk reduction activities. All prior contracts ended on August 31, After programs were funded on September 1, 2007, DSHS established a fi rst year new priority rating process to determine the timeline for site visits to the new contractors. As stipulated in the new risk assessment rating, a contractor will receive an assessment and technical assistance visit within six months of the contract start date if the program is implementing a new intervention, working with a new population, or working in a new venue. Programs performing the same intervention with no changes will remain on the established risk assessment rating. The program sends assessment and technical assistance documentation to each contractor for follow-up. After the fi rst year of funding, DSHS will revert to the previously established risk assessment process. HIV/STD Program Staff conducted 14 HIV prevention contract monitoring site reviews, one desktop review, and 26 technical assistance site visits in

43 VI. HIV MEDICAL AND SUPPORT SERVICES The Ryan White HIV/AIDS Treatment Modernization Act is the nation s largest HIV-specifi c federal grant program. It provides funds for medical and support services for persons living with HIV/AIDS (PLWHA) who cannot afford them. Federal Ryan White funds are combined with state general revenue funds and funds from local jurisdictions to provide medical and support services to eligible PLWHA in Texas. In Texas, an individual is eligible to receive Ryan White services if they have an HIV or AIDS diagnosis and are a bona fi de resident of Texas. The Texas HIV Medication Program has additional eligibility criteria, and some local areas set additional eligibility requirements for some services to assure fair distribution of resources. Characteristics of Clients Receiving Ryan White Eligible Services Information contained in this section summarizes services provided to Ryan White eligible clients statewide as reported through the Uniform Reporting System (URS). The URS combines information reported through AIDS Regional Information and Evaluation System, the reporting database for Ryan White funded providers outside of the Houston area, and Centralized Patient Care Data Management System, the reporting database for Ryan White funded providers in the Houston area. All Ryan White funded service providers report all Ryan White eligible services provided to Ryan White eligible clients, regardless of the funding stream paying for the service. Reporting of HIV-related services in this manner allows DSHS to report on all of the services that Ryan White eligible clients are accessing, not just those provided with Ryan White funds, and gives a more complete picture of client service usage. Antiretroviral and anti-opportunistic infection medications provided through the Texas HIV Medication Program (THMP) are not refl ected in the URS. Additionally, this summary does not report on the medical services provided to clients by all private providers or the entire Medicaid/Medicare system as those data are reported through separate and varied systems that are not accessible to the HIV/STD Program at this time. During 2007, 28,852 clients received at least one Ryan White eligible service from Ryan White providers in Texas. Of those receiving services, the majority was male (73 percent); 40 percent were African American, 29 percent were White, and 29 percent were Hispanic; and 37 percent were 35 to 44 years old and 84 percent were 25 to 54 years old. The population receiving services is only a segment of the entire population of persons living with HIV/AIDS. Table 13 compares the population of living HIV/AIDS cases in Texas to the population of those receiving services. Comparing these two populations reveals: A greater proportion of females among services clients than among PLWHA; A greater proportion of Hispanic clients among services clients than among PLWHA; A lower proportion of White clients among services clients than among PLWHA; and 43

44 There are more children receiving services than are infected. Infants who are exposed to HIV during birth are eligible to receive services. Many never become HIV positive. 1 Additionally, it appears that the population of PLWHA is slightly older than the services population. Thirty-seven percent of services clients are 45 and older compared to 42 percent of PLWHA. Table 13. Persons Living with HIV/AIDS and Services Clients by Select Characteristics, Texas, 2007 PLWHA 2007 Services Clients 2007 Number Percent Number Percent Total 62, , Sex Male 49, , Female 13, , Race/Ethnicity White 22, , African American 23, , Hispanic 15, , Other Age < , , , , , , , , , , PLWHA are estimated cases adjusted for reporting delay. The sum total of estimates for each category may not match the total due to rounding. The stated purpose of the Ryan White Program is to maintain HIV-infected persons in medical care, and therefore at least 75 percent of Part A, B or C funds must be spent on core medical services designated in the federal legislation. No more than 25 percent of funds may be spent on so-called support services; support services are limited to those explicitly outlined by HRSA. Table 14 compares clients receiving core services to those receiving any eligible service. A comprehensive list of core and support services is in Table 15. The population receiving core services greatly resembles the overall client population, with 87 percent of all clients receiving at least one core service during the year. Table 14 shows that for both sexes, each of racial/ethnic groups and for all of the age groups, more than 85 percent of each of these populations received at least one core service during the year. 1. Once it is established that perinatally-exposed children are not living with HIV, they are elibigle for a very restricted set of Ryan White program services. 44

45 Table 14. All Services Clients and Core Services Clients by Select Characteristics, Texas, 2007 All Clients Core Clients Percent Receiving Number Percent Number Percent Core Service Total 28, , Sex Male 20, , Female 7, , Race/Ethnicity White 8, , African American 11, , Hispanic 8, , Other Age < , , , , , , , , , , Table 15 shows each of the core and support services delivered by Ryan White Program providers during the year. The services are arranged so that the services that were accessed by the greatest number of clients are at the top. For example, outpatient/ambulatory medical care was the core service used by the most clients and case management (non-medical) was the support service used by the most clients. The mean (average), median, mode and range of the days the services were received are reported at the right side of the table. For nearly every service category, the mean is greater than the median. A large difference between these two values indicates that there are a small number of clients using the service with a greater intensity (for a large number of days), pulling the average beyond the midpoint (median). Core Services Outpatient/ambulatory medical care (OAMC) was the most frequently received core service with 66 percent of Ryan White eligible clients receiving at least one outpatient visit during the year. Following OAMC, medical case management was the core service accessed by the next greatest proportion of clients: 51 percent of clients received medical case management services with an average of nine days per client for this service. Next was oral health care and AIDS pharmaceutical assistance: oral health was reported for 24 percent of clients for an average of 4.3 days per client and drug reimbursement was reported for 23 percent of clients for an average of 7.2 days per client. Less than 10 percent of the clients received any one of the other core services. Of the remaining core services, outpatient substance abuse, home and community-based health services, and hospice had the largest average number of days per client, signifying that clients use these services with a greater intensity than is seen for other services. 45

46 Table 15. Overview of Services Provided Statewide, 2007 Statewide (n=28,852) Clients Number of Service Days # % mean median mode range Core Services Outpatient/Ambulatory Medical Care 18, Medical Case Management (including Treatment Adherence) 14, Oral Health Care 6, AIDS Pharmaceutical Assistance (local) 6, Mental Health Services 2, Health Insurance (premiums, deductibles, co-payments) 2, Medical Nutrition Therapy 2, Substance Abuse Services - Outpatient Early Intervention Services (Parts A and B) Home and Community-Based Health Services Hospice Services Home Health Care Support Services Case Management (non-medical) 14, Food Bank/Home-Delivered Meals 10, Medical Transportation Services 5, Emergency Financial Assistance 2, Outreach Services 2, Client Advocacy* 1, Psychosocial Support Services Health Education/Risk Reduction Housing Services Treatment Adherence Counseling (non-medical) Other Services* Referral for Health Care/Supportive Services Legal Services Respite Care Transportation* Linguistic Services Referrals to Clinical Research* Child Care Services Buddy/Companion Services* Substance Abuse Services - Residential *Not an eligible Ryan White Part B service; services are paid for with state general revenue funds. Support Services Non-medical case management was the support service accessed by the greatest proportion of clients (51 percent). The average number of days clients received this service was 8.8 with half of these clients receiving it on four or fewer days (median=4). After non-medical case management, food bank/home delivered meals and medical transportation services were the support services used by the greatest number of clients. Thirty-six percent of clients received food bank and/or meals for an average of 15.5 days per client. Medical transportation services 46

47 were reported for 19 percent of clients for an average of 8.4 days per client. Ten percent or less of clients received any one of other support services. Of these services, respite care, child care, and housing services were the support services used most intensely (highest average number of days). HIV Medical and Support Services Planning, 2007 In December 2006, the new Ryan White Treatment Modernization Act (RWTMA) became law. The new act contained signifi cant changes from the previous Ryan White Care Act of HIV/STD Program staff spent much of 2007 adjusting the service delivery system in Texas to comply with these changes. During the fi rst quarter of 2007, HIV/STD Program staff worked closely with regional Administrative Agency (AA) planners to evaluate local service allocations and make necessary adjustments to comply with the 75 percent core service spending required in the new act. The largest impact of reauthorization on the service delivery system in Texas was to case management. The Ryan White Program in Texas makes heavy use of case management to assess eligibility for services and entitlement programs, direct clients to needed services, coordinate care, and build client independence. Case management receives the second largest allocation, second behind medical care. In the reauthorized legislation, however, only medical case management was considered a core service, and expenditure on non-medical case management, along with other supportive services, was capped at 25 percent of the award. The legislation did not provide a clear defi nition of what activities constituted medical case management, and HRSA s defi nition was very broad and loose. Therefore, in the fi rst quarter of 2007, DSHS, in conjunction with the fi ve Part A administrators in Texas, developed a defi nition of medical case management. Staff then worked with local AA planners to complete a cursory evaluation of local case management agencies, staff, and activities to ensure that allocated funds accurately refl ected the new defi nitions of medical and non-medical case management activities. In the process of evaluating case management services described above, DSHS decided to investigate the HIV case management system in greater depth to better understand how the RWTMA affected case management services at the local level. DSHS commissioned the Brazos Valley Council of Governments in late 2007 to conduct a study to answer questions about and guide possible changes to the case management system. The study has four, distinct phases and will be fi nal in The fi rst two site observations were pilot sites to test the data collection instruments designed for the study and were complete in the fall of The DSHS work group and the contractor will next begin to collect data from site observations, complete an extensive literature review of case management, and survey partner jurisdictions and all case management agencies in Texas to understand current practices and develop recommendations for implementation of medical case management for HIV-infected persons in Texas. HIV/STD Program staff produced the Statewide Coordinated Statement of Need (SCSN) to be fi nal in The purpose of developing the SCSN is to provide a collaborative mechanism 47

48 to identify and address signifi cant HIV care issues and to maximize coordination, integration, and effective linkages across the Ryan White Parts. Success of this document is due in large part to the Ryan White program grantee representatives, local providers, and persons living with HIV/AIDS that acted as key informants and provided input and direction in its development in three statewide stakeholder meetings convened by the HIV/STD Program in The document refl ects existing needs assessments and includes a brief overview of epidemiologic data, identifi es the cross-cutting issues, gaps and barriers to service, issues needing more study, and emerging trends affecting HIV care and service delivery in Texas. The document is on the DSHS Website at: The HIV/STD Program convenes planner s network meetings of all Part B planners in Texas to facilitate peer technical assistance and as a forum for DSHS to provide information, updates, technical assistance, and training. The HIV/STD Program conducted three planner s network meetings in HIV/STD Program staff provided technical assistance on changes to service delivery resulting from RWTMA, changes to case management systems, integrating HIV prevention into service delivery, and conducting qualitative assessments in their areas. Comprehensive needs assessments for the North Central Texas plan area, the NE Texas plan area, the East Texas plan area, and the Houston EMA were underway in The results will be published in The West and South Texas Administrative Agencies (AA), including the San Antonio TGA, completed the groundwork and planning for assessments that will begin In West Texas, the assessment will focus on access to medication services. In South Texas, the plan is to conduct general comprehensive assessments with no focus on specifi c populations and/or issues. Figure 18. An Overview of Planning Areas in Texas 48