1. 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

2. Health Department Substance Abuse Agency Mental Health Agency Texas Department of State Health Services (DSHS) Became Operational on September 1, 2004 2

3. Department of State Health Services Vision — A healthy Texas Mission — To improve health and well-being in Texas 3

4. 4

5. U.S. Life Expectancy at Birth 1918 Flu Epidemic 5

6. 6 Life Expectancy in Texas Total and by Race, 1989 - 2007

7. 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.htmhttp://www.cdc.gov/mmwr/preview/mmwrhtml/00056796.htm Increased years due to medical care advances: 5 Increased years due to public health measures : 25 7

8. 8 Impact of Vaccines in the 20 th Century Disease20 th Century Annual Morbidity 2006 Total% Decrease Smallpox48,1640100 Diphtheria175,8850100 Pertussis147,27115,63289 Tetanus1,3144197 Polio (paralytic)16,3160100 Measles503,28255>99.9 Mumps152,2096,58496 Rubella47,74511>99.9 Congenital rubella823199.8 Haemophilus influenzae (<5 yrs) 20,000 (est.)208 (serotype B or unknown serotype) 99

9. 9 Number of Cases and Incidence of Hep-A in Texas, 2000 - 2009

10. 10 Number of Cases and Incidence of Hep-B, Acute in Texas 2000 - 2009

11. 11 Leading Causes of Death 1900 Pneumonia Tuberculosis Diarrhea Heart Disease Intracranial Lesions 2007 Heart Disease Cancers Accidents Cerebrovascular Disease Chronic Lower Respiratory Diseases

12. 12 Ten Leading Causes of Death in Texas, 2007

13. 13 Ten Leading Causes of Death in Texas, Ages 18 – 44 Years, 2007

14. 14 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

15. 15 Texas’ Major Infectious Disease Challenges: 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): –4 th in syphilis rates –15 th in gonorrhea rates –17 th in Chlamydia rates

16. Chlamydia Cases by Year of Report: Texas, 2000-2009 16

17. 17 Gonorrhea Case Rates in Texas By Race / Ethnicity, 1999 - 2009

18. 18 Primary & Secondary Syphilis Case Rates in Texas, 1999 - 2009

19. 19 Texas’ Major Infectious Disease Challenges: 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

20. 20 Newly Diagnosed HIV Cases, Deaths, & Persons Living with HIV (Texas, 1980-2008) New HIV Cases Deaths among HIV Cases Living with HIV

21. 21 Persons Living with HIV, 1987

22. 22 Persons Living with HIV, 1997

23. 23 Persons Living with HIV, 2007

24. 24 Newly-diagnosed HIV Cases*: Texas, 1999-2008 * AIDS cases were diagnosed with AIDS within 1 month of HIV diagnosis

25. Racial Disparity in Persons Living with HIV/AIDS in Texas (2001 – 2006) 25

26. 48% 11% 36% 5% Newly-diagnosed HIV Cases by Race/Ethnicity: Texas, 2008 43% 29% 26% 2% White Hispanic Other/Unknown Black Texas Population n=24,383,647 New HIV Cases n=4,293 26

27. 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). 27

28. 28 Texas’ Major Infectious Disease Challenge: 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

29. 29 Number of TB Cases Texas 1999-2008

30. 30 Tuberculosis Incidence Rates Along Texas-Mexico Border, Texas 1999-2008

31. 31 TB Case Rates in Texas, by Race 2000 - 2009

32. 32 Number of Foreign-Born TB Patients in Texas, 2000 - 2009

33. 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 services 33

34. 34 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

35. 35 Essential Partners for Infectious Disease Control Local health departments Regional public health State program National – CDC International Academia Private sector

36. 36 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

37. 37 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

38. 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 38

39. 39 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

40. 40 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

41. Source: Department of State Health Services Program data, HIV/STD Prevention and Care Branch 41 Routine HIV Tests Conducted by Routine HIV Testing Projects Funded by DSHS & City of Houston, 2009

42. 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 42

43. 43 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 http://www.dshs.state.tx.us/hivstd/ept/default.shtm

44. 44 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

45. 45 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

46. 46 Treatment Challenges Treatment is now primarily outpatient Requires legwork Requires meticulous follow up

47. 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 47

48. 48 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

49. 49 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

50. 50 Texas Center for Infectious Disease (TCID)

51. 51

52. Major Issues During 82 nd Legislative Session Redistricting Immigration issues Healthcare reform Budget challenges –Previous Reductions –Budget reduction schedule –Growth of entitlement programs –Requests for new or expanded programs 52

53. 53 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

54. FY 2012-3 Base by Strategy GOAL2010-11All Funds2012-13 All Funds A. Preparedness & Prevention Services 1,243,611,4341,086,689,573 B. Community Health Services3,706,877,8553,656,431,475 C. Hospital Facilities and Services874,304,269883,276,458 D. Consumer Protection Services145,847,016145,049,554 E. Indirect Administration112,204,513117,068,159 F. Capital Items78,392,89764,129,014 TOTAL6,161,237,9845,952,644,233 54

55. FY 2010-11 Appropriations (By Goal) 55

56. StrategyDescriptionFirst 5%Second 5%Total A.2.1Immunizations – Adult101 A.2.1Immunizations – Children07.7 A.3.1Children’s Outreach Health Program0.50 A.3.1Diabetes0.5 1 A.3.1Obesity Prevention101 A.3.3Kidney Transportation4.50 A.3.3Donate Life Registry0.40 A.3.3Kidney Medical167 A.3.4Children with Special Health Care Needs024 A.3.5Epilepsy0.450 B.1.1Farmer’s Market0.850 B.1.2Women & Children’s Services – Dental Services01.6 B.1.4Primary Care639 B.2.1 – B.2.4Community Mental Health Services35.347.983.2 B.2.5Substance Abuse Intervention404 B.3.1EMS/Trauma20525 B.3.3Indigent Health Care Reimbursement to UTMB4.548.5 B.3.4County Indigent606 C.1.2South Texas Health Care system2.5 5 C.1.3State Mental Health Hospital System3014.844.8 D.1.4Massage Therapy01.5 E.1.1 – E.1.3Support Activities0.7 1.4 TOTAL119.2 238.4 Ten Percent Reduction Options (By Strategy) 56

57. 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 57

58. 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 58

59. Exceptional Item Requests Maintain 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 59

60. FY 2012FY 2013Biennium HIV Medications---22,668,987 Kidney Health Care---846,983 Montgomery County Annualized7,500,00015,000,00022,500,000 Regulatory Services Annualized2,510,7802,510,7795,021,559 Newborn Screening Annualized479,793479,973959,586 Vital Statistics Annualized220,796220,795441,591 Agency Costs – Utilities, Transportation, Postage 1,710,5352,915,0604,625,595 Replace Aging Vehicles151,357174,176325,533 Total12,573,26144,816,57357,389,834 Exceptional Item 1 60

61. Texas’s Funding for HIV 20092010201120122013 State GR $ 51.4 M$ 55.0 M$ 55.1 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 61

62. 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 62

63. 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 63

64. 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 System 64

65. 65 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

66. FY 2012FY 2013Biennium Texas Center for Infectious Disease – Full Capacity 1,435,6542,380,1543,815,808 Tuberculosis and Pediatric Protection 1,467,3521,566,0583,033,410 Improve immunization data collection and other surveillance systems 3,250,0001,250,0004,500,000 Total6,153,0065,196,21211,349,218 Infectious Disease Prevention Exceptional Item 12 66

67. 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 progress 67

68. Thank You!

70. 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 81 st 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 70