Riding the Waves September 16 & 17, 2010

“Public Health Strategies to Address STDs, HIV & TB in Texas”

David Lakey, M.D.Commissioner

Texas Department of State Health Services

Health Department

Substance Abuse Agency

Mental Health Agency

Texas Department of State Health Services (DSHS) Became Operational on September 1, 2004

2

Department of State Health Services

• Vision — A healthy Texas

• Mission — To improve health and

well-being in Texas

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4

U.S. Life Expectancy at Birth

30

40

50

60

70

1900 1910 1918 1920 1930 1940 1950 1960

1918 Flu Epidemic

5

6

Life Expectancy in TexasTotal and by Race, 1989 - 2007

Increased Life Expectancy Driven by Public Health Improvements

Source: Ten Great Public Health Achievements -- United States, 1900-1999 MMWR, April 02, 1999 / 48(12);241

243 http://www.cdc.gov/mmwr/preview/mmwrhtml/00056796.htm

77 years

47 years

0

20

40

60

80

1900 2000

Increased years due to

medical care advances:5

Increased years due to

public health measures:

25

7

8

Impact of Vaccines in the 20th Century

Disease 20th Century Annual Morbidity

2006 Total % Decrease

Smallpox 48,164 0 100

Diphtheria 175,885 0 100

Pertussis 147,271 15,632 89

Tetanus 1,314 41 97

Polio (paralytic) 16,316 0 100

Measles 503,282 55 >99.9

Mumps 152,209 6,584 96

Rubella 47,745 11 >99.9

Congenital rubella 823 1 99.8

Haemophilus influenzae (<5 yrs)

20,000 (est.) 208 (serotype B or unknown

serotype)

99

9

Number of Cases and Incidence of Hep-A in Texas, 2000 - 2009

10

Number of Cases and Incidence of Hep-B, Acute in Texas 2000 - 2009

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Leading Causes of Death

1900• Pneumonia• Tuberculosis• Diarrhea• Heart Disease• Intracranial Lesions

2007• Heart Disease• Cancers• Accidents • Cerebrovascular

Disease

• Chronic Lower Respiratory Diseases

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Ten Leading Causes of Death in Texas, 2007

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Ten Leading Causes of Death in Texas, Ages 18 – 44 Years, 2007

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Infectious Diseases no Longer Leading Causes of Death in the United States

However:

• ~1 million Americans infected with HIV– ¼ are unaware of their infection

• Chronic liver disease: 10th leading cause of death in U.S.– More than half of these deaths due to viral hepatitis– Hepatitis C is most common blood-borne disease in U.S.

• ~19 million cases of non-HIV STDs occur each year – Chlamydia and gonorrhea are most commonly reported infectious

diseases

• ~10-15 million in U.S. have latent TB infection– 13,767 had TB in 2006

Furthermore: Infectious Disease are inherently contagious and can quickly resurge

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Texas’ Major Infectious DiseaseChallenges: STDs

• ~ 87% of the top ten reported infectious diseases are sexually transmitted, including Chlamydia, gonorrhea, syphilis and HIV

• In 2009, 139,600 STD infections, excluding HIV / AIDS, were reported in Texas

– an increase of 2% from 2008

• Texas’ ranking among states (2008):– 4th in syphilis rates– 15th in gonorrhea rates– 17th in Chlamydia rates

Chlamydia Cases by Year of Report:Texas, 2000-2009

58%58%59%60%62%62%63%63%63%63%

010,00020,00030,00040,00050,00060,00070,00080,00090,000

100,000110,000

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Year

Cas

es

Males All AgesFemales Other AgesFemales Age 15-24

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17

Gonorrhea Case Rates in Texas By Race / Ethnicity, 1999 - 2009

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Primary & Secondary Syphilis Case Rates in Texas, 1999 - 2009

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Texas’ Major Infectious DiseaseChallenges: HIV/AIDS

• Between 2002 - 2008, the number of living HIV/AIDS cases in Texas rose ~6% a year– The increase reflects extended survival due to better

treatment and not an increase in new diagnoses

• During the same period, new HIV diagnoses stayed stable at ~4,500 per year, and deaths at ~1,200 year

• In 2008, the rate among blacks was 4 - 5 times higher than the rates in whites and Hispanics– Blacks also had the highest number and rate of newly

diagnosed infections • 5-7 times higher than the rates for Hispanics and whites

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Newly Diagnosed HIV Cases, Deaths, & Persons Living with HIV (Texas, 1980-2008)

0

1000

2000

3000

4000

5000

6000

7000

8000

80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08

Year

New

HIV

Cas

es /

Dea

ths

0

10000

20000

30000

40000

50000

60000

70000

Per

son

s L

ivin

g w

ith

HIV

New HIV Cases

Deaths among HIV Cases

Living with HIV

21

Persons Living with HIV, 1987

22

Persons Living with HIV, 1997

23

Persons Living with HIV, 2007

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Newly-diagnosed HIV Cases*:Texas, 1999-2008

0

1000

2000

3000

4000

5000

6000

7000

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Year

Cas

es

AIDSHIV

* AIDS cases were diagnosed with AIDS within 1 month of HIV diagnosis

22,439

16,388

23,119

15,18414,417

8,936

0

5,000

10,000

15,000

20,000

25,000

2001 2002 2003 2004 2005 2006

Year

Num

ber

White Black Hispanic

196.7146.6

615.9

868.3

170.2128.4

0

100

200

300

400

500

600

700

800

900

1000

2001 2002 2003 2004 2005 2006

Year

Rat

e pe

r 10

0,00

0

White Black Hispanic

Racial Disparity in Persons Living with HIV/AIDS in Texas (2001 – 2006)

25

48%

11%

36%

5%

Newly-diagnosed HIV Cases by Race/Ethnicity: Texas, 2008

43%

29%

26% 2%

White

Hispanic

Other/Unknown

Black

Texas Populationn=24,383,647

New HIV Casesn=4,293

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Rate of New HIV Diagnoses by Sex & Race / Ethnicity

Source: 2010 Texas Integrated Epidemiologic Profile for HIV/AIDS Prevention and Services Planning: HIV/AIDS in Texas, Department of State Health Services, Publication Number E13-11937 (Revised April 2010).

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Texas’ Major Infectious DiseaseChallenge: TB

• Texas ranks 2nd in the United States in number of TB cases after California– Approximately 13% of all US cases are from Texas

• The number of Texas cases has declined by ~15% since 1998

• The rate has decreased from 9.1 per 100,000 in 1998 to 6.0 in 2009

• The percent of foreign born TB cases continues to rise as does the incidence of:– Multidrug-resistant (MDR) cases, and– Comorbidities – Makes effective treatment more challenging

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1640

1496

1630

1539

1580

1670

1524

1566

15101501 1501

1400

1450

1500

1550

1600

1650

1700

Cases

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Year

Number of TB Cases Texas 1999-2008

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Tuberculosis Incidence Rates Along Texas-Mexico Border,

Texas 1999-2008

11.611.112.212.312.9

13.112.813.313.112.5

5.65.86.16.16.86.56.57.16.6

7.7

0

2

4

6

8

10

12

14

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Year

Cas

es p

er 1

00,0

00 p

opul

atio

n

Texas Border Texas NonBorder

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TB Case Rates in Texas, by Race 2000 - 2009

32

Number of Foreign-Born TB Patients in Texas, 2000 - 2009

Syndemics (Overlapping Epidemics)

• Similar or Overlapping at-risk Populations

• Disease Interactions– Common transmission for HIV, hepatitis & STDs– STDs increase risk of HIV infection– HIV is greatest risk factor for progression to TB– HIV accelerates liver diseases associated with viral hepatitis

• Social Determinants

• Prevention and Control– Control of TB, viral hepatitis and STDs needed to protect health

of HIV-infected persons– Challenges in funding, delivery, monitoring and quality of

prevention services33

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Modernizing Prevention Responses

• Improve data systems• Embrace new technologies that improve

early diagnosis and treatment• Embrace the use of social media for

information & interventions • Support implementation of US Preventative

Services Task Force recommendations– Only 1/3 of sexually active young females are

receiving recommended screenings in Texas

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Essential Partners for Infectious Disease Control

• Local health departments

• Regional public health

• State program

• National – CDC

• International

• Academia

• Private sector

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The DSHS HIV / STD Program

• The HIV / STD Program prevents the spread of HIV and other STDs and minimizes disease complications and costs by: – Providing information & education– Using evidence-based interventions, counseling, screening and testing – Partner elicitation and notification, and – Medical and social services

• The HIV / STD Program consists of 2 branches, the TB / HIV / STD Epidemiology & Surveillance Branch and the HIV / STD Prevention & Care Branch– Both branches are located in the TB/HIV/STD Unit

• The program provides some direct services – Local health departments and community organizations provide

most HIV/STD-related services through contracts with DSHS

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HIV / STD Program Priorities• Increase

– the number of Texans living with HIV who get treatment

• Reduce– new HIV infections

– new STD infections

– late diagnosis of HIV infection

– racial/ethnic disparities in HIV and STD

• Enhance HIV/STD surveillance

• Promote integration of services

Program Collaboration & Service Integration (PCSI)

• PCSI is an approach to integrate the responses to interrelated health issues, activities & prevention strategies to facilitate comprehensive, client-focused services

• One key DSHS value is to develop and expand integration of public health, mental health, substance abuse and other behavioral services

• HIV and STD programs have been successfully integrated at DSHS since 1987

• In late 2008, surveillance and epidemiology functions were integrated for TB, HIV, and STD

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HIV Funds Received (FY 2010-2011)

• Legislature instructed DSHS to target ~$4.4 million each

year to increase HIV testing in high morbidity areas – Houston and Dallas given top consideration

• The DSHS HIV program worked with numerous internal and external partners to create the Test Texas HIV Coalition and:– Form a peer network to increase adoption of routine testing

recommendations– Provided increased access to training and technical assistance

• DSHS ramped up contractual activity with large hospital emergency departments, jails and community health clinics to provide routine HIV testing

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HIV Expanded Testing Initiative

• Funds for enhanced testing efforts targeted correctional facilities, Emergency Departments & FQHCs

• HIV NAAT testing took place in the Dallas County Health Department lab to indentify acute HIV infections

• All Texas public health labs now use state-of-the-art amplified testing technology to provide rapid results for HIV and other STDs

Source: Department of State Health Services Program data, HIV/STD Prevention and Care Branch

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Routine HIV Tests Conducted byRoutine HIV Testing Projects Funded by DSHS

& City of Houston, 2009

HIV Expanded Testing Initiative

• DSHS is committed to the expansion of routine, integrated HIV testing in health care settings

– Key strategy for reducing new HIV infections– Working to expand routine HIV testing within DSHS– Recruit and support of new facilities and clinics– Support general education and diffusion of routine

testing practices, especially among private physicians

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Expedited Partner Therapy (EPT)

• EPT treats sex partners of persons with an STD without an intervening medical evaluation or professional prevention counseling of the partner

– Typically through patient-delivered partner therapy

• The Texas Medical board has endorsed EPT

• DSHS has created an EPT fact sheet – Explains why a health care provider would use EPT, and – How it works

– Fact sheets to educate partners are available at http://www.dshs.state.tx.us/hivstd/ept/default.shtm

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HIV Counseling, Testing & Referral (CTR) for High-Risk Individuals

• CTR programs:– Inform individuals of their HIV status

– Encourage risk behavior change, and

– Link clients to appropriate services

• The Texas HIV/STD Program currently funds 23 programs

• In 2009, DSHS CTR contractors performed over 30,000 HIV tests – With a new positivity rate of 1.0% 

• In addition to our long history working with CTR programs:– DSHS implemented social networking strategies in late 2009 to improve

the identification of newly HIV infected persons

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Advances in TB Care • New diagnostic tests will provide more

specific diagnosis

– Skin test 100 years old, but still in widespread use– Currently, 2 FDA-approved blood tests in use in

limited areas of Texas

• Drug sensitivity tests– New genetic tests detect drug resistance mutations

to critical drugs (INH & rifampin) more quickly– Conventional tests take about 28 days but genetic

tests can be completed in 2 days

• New TB drugs currently in clinical trials

• Potential development of vaccines– May be years in the future

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Treatment Challenges

• Treatment is now primarily outpatient

• Requires legwork

• Requires meticulous follow up

Infectious Disease Successes: Tuberculosis

U.S. Bi-national Initiatives: • CureTB is a US-Mexico bi-national tuberculosis referral

program that, since 1997, has facilitated continuity of care of TB patients moving between the United States and Mexico

Texas “Sister City” Bi-national Initiatives:• Brownsville and Matamoros• McAllen and Reynosa • Laredo and Nuevo Laredo • El Paso and Juarez• Eagle Pass and Pierdas Negras • Del Rio and Ciudad Acuña

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TB Funds Received (FY 2010-2011)

• Appropriated ~$7,000,000 for the biennium for TB prevention and control to:– Support increased prevention and control activities at the regional

and local level

– Support special projects at the regional and local level to focus on:• Blacks at increased risk, • Patient-centered interventions, • Homeless persons with TB, and • Children with TB who need case management

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The Texas Center for Infectious Disease (TCID)

• TCID is a DSHS facility. It is the largest new construction in the US in the last 50 years for inpatient care & treatment for TB patients. It provides:– Patient care,

– Scientific investigation,

– Therapeutic and educational services supporting public health needs

• TCID's Outpatient Clinic also serves as one of the state's Hansen Disease Clinics 

• Construction completed on 22SEP10

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Texas Center for Infectious Disease (TCID)

Texas Center for Infectious Disease (TCID)

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Major Issues During 82nd Legislative Session

• Redistricting

• Immigration issues

• Healthcare reform

• Budget challenges– Previous Reductions– Budget reduction schedule– Growth of entitlement programs– Requests for new or expanded programs

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DSHS Legislative Appropriations Request

• DSHS continues reductions made in the current biennium as part of the HHS System approach to the 5% reduction to the budget – The request includes additional 10% GR reduction options.

• DSHS prioritized options to mitigate the impact on community services and safety net health programs

• The LAR includes 12 exceptional items to: – Maintain operating capacity in existing program– Ensure compliance with state and federal requirements, and– Move health forward in Texas

FY 2012-3 Base by Strategy

GOAL 2010-11All Funds 2012-13 All Funds

A. Preparedness & Prevention Services

1,243,611,434 1,086,689,573

B. Community Health Services 3,706,877,855 3,656,431,475

C. Hospital Facilities and Services 874,304,269 883,276,458

D. Consumer Protection Services 145,847,016 145,049,554

E. Indirect Administration 112,204,513 117,068,159

F. Capital Items 78,392,897 64,129,014

TOTAL 6,161,237,984 5,952,644,233

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$0

$100

$200

$300

$400

$500

$600

$700

$800

$900

$1,000

(in

mil

lio

ns)

Goal A Goal B Goal C Goal D Goal E Goal F

GR

GRD

FY 2010-11 Appropriations(By Goal)

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Strategy Description First 5% Second 5% Total

A.2.1 Immunizations – Adult 1 0 1

A.2.1 Immunizations – Children 0 7.7 7.7

A.3.1 Children’s Outreach Health Program 0.5 0 0.5

A.3.1 Diabetes 0.5 0.5 1

A.3.1 Obesity Prevention 1 0 1

A.3.3 Kidney Transportation 4.5 0 4.5

A.3.3 Donate Life Registry 0.4 0 0.4

A.3.3 Kidney Medical 1 6 7

A.3.4 Children with Special Health Care Needs 0 24 24

A.3.5 Epilepsy 0.45 0 0.45

B.1.1 Farmer’s Market 0.85 0 0.85

B.1.2 Women & Children’s Services – Dental Services 0 1.6 1.6

B.1.4 Primary Care 6 3 9

B.2.1 – B.2.4 Community Mental Health Services 35.3 47.9 83.2

B.2.5 Substance Abuse Intervention 4 0 4

B.3.1 EMS/Trauma 20 5 25

B.3.3 Indigent Health Care Reimbursement to UTMB 4.5 4 8.5

B.3.4 County Indigent 6 0 6

C.1.2 South Texas Health Care system 2.5 2.5 5

C.1.3 State Mental Health Hospital System 30 14.8 44.8

D.1.4 Massage Therapy 0 1.5 1.5

E.1.1 – E.1.3 Support Activities 0.7 0.7 1.4

TOTAL 119.2 119.2 238.4

Ten Percent Reduction Options(By Strategy)

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Ten Percent Reduction Options

• $137 million – Reductions in State Mental Health Hospital capacity, Community Mental Health Services for adults and children, and Substance Abuse Intervention services

• $58 million – Reductions in several programs that provide health and dental services, including vaccination, primary care and services for children with special health care needs, among others

• $41 million – Reductions in funding for uncompensated care reimbursed to counties and hospitals, as well as prevention and education programs

• $3 million – Reductions in support and administrative savings

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• Exceptional Items in priority order, ranked according to:– Maintaining current services– Ensuring compliance with state and

federal requirements– Moving health forward in Texas

Exceptional Item Requests

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Exceptional Item RequestsMaintain Current Services

• Maintain current services and gaps• $57.4 million GR/AF

– Increasing caseload – HIV and Kidney Health Care– Annualized Services - MH Forensic Facility, Regulatory,

Newborn Screening and Vital Statistics– Increasing Cost– Vehicles

• Maintain Hospital Operations• $42.6 million GR/AF

– Increasing Cost – Medication, Medical services, food, supplies and utilities

– Salary Increase for critical positions– Additional Staffing Requirements– After Hours Pharmacy Coverage

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FY 2012 FY 2013 Biennium

HIV Medications --- 22,668,987 22,668,987

Kidney Health Care --- 846,983 846,983

Montgomery County Annualized 7,500,000 15,000,000 22,500,000

Regulatory Services Annualized 2,510,780 2,510,779 5,021,559

Newborn Screening Annualized 479,793 479,973 959,586

Vital Statistics Annualized 220,796 220,795 441,591

Agency Costs – Utilities, Transportation, Postage

1,710,535 2,915,060 4,625,595

Replace Aging Vehicles 151,357 174,176 325,533

Total 12,573,261 44,816,573 57,389,834

Exceptional Item 1

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Texas’s Funding for HIV

2009 2010 2011 2012 2013

State GR $ 51.4 M $ 55.0 M $ 55.1 M $ 55.0 M $ 55.0 M

Federal Funds

$125.2 M $141.0 M $132.6 M $ 113.0 M $111.8 M

Total $176.6 M $196.0 M $ 187.7 M $ 168.0 M $166.9 M

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Exceptional Item Requests(continued)

Maintain FY10-11 Services

• Return to regular FMAP after ARRA Expiration and Restore ARRA TANF ($6.7 million GR/AF)– Maintain Current Capacity at North Texas State Hospital– Restore TANF Funds for Family Planning Services

• State Hospital Capacity ($22.3 million GR/ $24.6 million AF)– Alternatives to hospitalization for long term patients– Stipends for Psychiatrist and Nurse Practitioner Residents– Peer Support

• Hospital Equipment/Repair and Renovation ($15.5 million GR/ $84.4 million AF)– Critical equipment– Vehicles– Building Renovation and Repair

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Exceptional Item Requests(continued)

Compliance with State/Federal Statutes

• Patient safety ($5.5 million GR/AF)– Healthcare associated infections and preventable adverse

events– Statewide prevention efforts– Quality assurance teams

• Food and Environmental Safety ($5.7 million GR/AF)– Improve the detection and investigation of food-borne illnesses– Increase efficiencies in regulatory processes by sharing data

and providing access to license and enforcement cases online– Improve the collection and investigation of blood lead testing to

identify and screen children who are at risk for lead poisoning

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Exceptional Item Requests(continued)

Move Health Forward

• Healthy babies ($11.7 million GR/$12.9 million AF)– Reduce 3 main causes of infant mortality (SIDS, prematurity,

birth and genetic defects) through a public-private partnership– Sustain and improve the collection of birth defect data– Expand newborn screening and case management for the

secondary panel of newborn screening conditions

• Community MHSA services ($18.6 million GR/$21 million AF)– Collaborative projects for jail diversion– Comprehensive prevention and treatment response targeted at

border communities– Expand capacity of the Clinical Management Behavioral Health

System64

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Exceptional Item Requests(continued)

• Obesity prevention ($4 million GR/AF)– Evidence based obesity prevention and control in

communities to improve nutrition and increase physical activity

• Preventable hospitalization ($5.1 million GR/AF)– Reduce preventable hospitalizations with grant funding

• Infectious disease prevention ($11.3 million GR/AF)– Increased capacity at the Texas Center for Infectious Disease– Improve TB identification and treatment– Reduce the number of pediatric hospitalizations due to

gastroenteritis– Improve reporting and surveillance tools

FY 2012 FY 2013 Biennium

Texas Center for Infectious Disease – Full Capacity

1,435,654 2,380,154 3,815,808

Tuberculosis and Pediatric Protection

1,467,352 1,566,058 3,033,410

Improve immunization data collection and other surveillance systems

3,250,000 1,250,000 4,500,000

Total 6,153,006 5,196,212 11,349,218

Infectious Disease PreventionExceptional Item 12

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Summary• Due to improvement in public health, the mortality of

infectious diseases as a whole has significantly decreased over the last century

• However, STDs and HIV continue to cause significant morbidity and their rates continue to increase

• Gradual improvements in TB morbidity in Texas

• Success of new tools and strategies to fight these disease

• A difficult legislative session lies ahead

• Partnerships are essential to continue progress67

Thank You!

Incidence of Hepatitis C, Acute in Texas, 2000-2009

0

50

100

150

200

250

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Num

ber

of C

ases

0

0.2

0.4

0.6

0.8

1

1.2

Rat

e pe

r 10

0,00

0 po

pula

tion

Case count Incidence Rate

Texas Public Health Successes• Childhood Immunizations

– Texas was named the most improved state in childhood immunizations by the U.S. Centers for Disease Control and Prevention

– San Antonio/Bexar County was named the most improved city/county

• Preparedness– Texas one of 7 states with highest score by TFAH– H1N1 and Hurricane responses

• Tobacco– The number of communities with smoke-free ordinances has increased

from two in 2000, to 47 in 2009

• Increased funding– During 81st Legislative session, 12 of 13 exceptional items were partially

funded to include: obesity, family planning, TB, HIV testing, community mental health, Cystic Fibrosis, disaster response and regulatory services

– Total increase $230 million over biennium

• Substance abuse Medicaid benefit

• Improved mental health crisis services

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