HIV and Viral Hepatitis Prevention and Treatment Resources in Texas

February 2013

Introduction to Resource Information on HIV, AIDS, and Hepatitis

Under House Bill 1370 of the 80th Texas Legislative Session, the Interagency Council on HIV and Hepatitis (Council) must put together an inventory of all federal, state, and local money spent in Texas on: 

• HIV infection 
• AIDS  
• Hepatitis prevention 
• Healthcare services  

This includes services provided through or covered under Medicaid and Medicare. It can be hard to gather complete and accurate information on resources directed toward HIV, AIDS, and hepatitis efforts. Even though the Council strives to report the most recent information, the budget tables are a “snapshot” of reported resources. The information below only contains budget information and activities reported to the Council by other state programs and agencies.

Federal, State, and Local Funds Spent on HIV Prevention and Care 

This section contains a compilation of federal, state, and local money spent on HIV prevention and care services reported to the Council. Members of the Council were asked for their expenditures associated with HIV in the previous year. Within the Texas Department of State Health Services (DSHS), the Council focused on major funding streams that provided support for HIV prevention and treatment. While general health, women’s health, and family planning programs provide access to HIV prevention services, these are not easily separated from integrated services. The complete list of local funds is unavailable for this report. Medicare, Veterans Administration expenditures, and non-Medicaid indigent care efforts also are not captured here. Finally, this summary does not include state and federal resources associated with inpatient hospitalizations. Sources of data on inpatient billings were not segregated by the source of payment. The absence of inpatient charges deflates treatment and care figures; however, less than ten percent of the lifetime cost of care for an HIV-infected person is attributable to inpatient hospitalization. The following tables provide summaries of the estimated federal, local, and state funds currently appropriated, awarded, and/or spent on HIV prevention and care services in Texas.
 

Table 1. Summary of HIV/AIDS Prevention and Treatment Resources Funding Resources for HIV/AIDS Care and Treatment Services in Texas

Type of Funds	Service Description	Amount
HIV/AIDS Treatment and Care Services	This amount includes federal and state funding for outpatient medical and support services including Medicaid. It does not reflect local funds devoted to indigent care, inpatient care, care paid for by the Veterans’ Administration or Medicare, or care delivered in correctional settings.	$271,789,179
HIV/AIDS Prevention	This amount includes federal and state funding through a variety of delivery mechanisms at the state and local levels.	$69,887,795
Total		$337,618,731

Table 2 summarizes major federal and state funding streams for HIV care and treatment. All figures represent 12 months, but the actual months covered vary which is detailed in the footnotes. Table 2 also shows the type of funds, a description of services provided by the funds, and reported annualized amounts. Immediately following the table are full descriptions of the different programs providing HIV/AIDS care and treatment services in Texas.
 

Table 2. Funding Resources for HIV/AIDS Care and Treatment in Texas

Type of Funds	Service Description	Amount
Ryan White Program (Part A through F) (Federal) [1]	Provides medical and supportive services for persons with HIV including the AIDS Drug Assistance Program (ADAP); also includes program administrative figures.	$132,057,893
Medicaid (Federal and State) [2]	Provides outpatient medical services and HIV-related drugs from Medicaid programs.	$73,973,999
State Appropriated Funds (State) [3]	Provides direct medical and supportive services for persons with HIV; includes funds for drugs purchased through the ADAP. Excludes prevention and surveillance.	$46,960,216
Housing Opportunities for People with AIDS (HOPWA) (Federal) [4]	Provides tenant-based and emergency housing assistance for persons living with HIV/AIDS and their families. These funds are federal and come both to the state and directly to local communities.	$18,797,071
Total		$271,789,179

Ryan White Program

The Ryan White Program (authorized by the HIV/AIDS Treatment Extension Act of 2009) provides funding for medical and supportive services to Persons Living with HIV (PLWH). The majority of grants available through this act require that at least 75 percent of funds be spent on core medical services. Part A funds go to metropolitan areas that meet certain thresholds of reported AIDS cases. Part B funds go to the state (through DSHS) to provide medical and support services for a person living with or affected by HIV and AIDS. Part B also provides funds for the AIDS Drugs Assistance Program, which provides HIV medications to low-income Texans with no or inadequate insurance. Part C grants go directly to clinics and support HIV clinical early intervention services. Part D grants go directly to local communities to provide family-centered treatment and support services for women, infants, children, and youth. Part F grants fund Special Projects of National Significance, AIDS Education Training Centers, dental programs, and the Minority AIDS Initiative (MAI).

Medicaid 

Medicaid is the state and federal cooperative venture that provides medical coverage to eligible needy persons. Medicaid serves primarily low-income families, non-disabled children, related caretakers or dependent children, pregnant women, the elderly, and people with disabilities.

State Revenue for Direct Client HIV Care and Treatment Services 

State Revenue funds are distributed through DSHS to local communities for medical care and services such as transportation, case management, food, and housing. These funds also purchase medications through ADAP to provide HIV medications to low-income Texans with inadequate or no insurance.

Housing Opportunity for Persons with AIDS (HOPWA) 

The HOPWA program provides housing assistance and supportive services to income-eligible PLWH and their families. The purpose of this program is to establish or better maintain a stable living environment in decent, safe, and sanitary housing to reduce the risk of homelessness and to improve access to healthcare and support services.

Substance Abuse and Mental Health Services Administration (SAMHSA) 

SAMHSA provides Texas with funding to provide case management services for PLWH at substance abuse treatment facilities.

Funding Resources for HIV Prevention in Texas 

The following table summarizes the major state and federal funding streams for HIV prevention. All figures represent 12-month periods, but the actual months covered vary from source to source, as detailed in the footnotes. This does not reflect local expenditures on prevention. The table shows the source of funds, types of services provided by the funds, and the reported annualized amounts.

Table 3. Funding Resources for HIV Prevention in Texas

Type of Funds	Service Description	Amount
Centers for Disease Control and Prevention (CDC) Cooperative Agreements (Federal) [5]	Provides counseling, testing and referral, partner services, and evidence-based risk reduction interventions primarily for those at high risk. Supports limited routine HIV testing in medical care settings. Funding comes through DSHS and the City of Houston and directly to local agencies.	$35,196,953
Houston/Harris County (Local) [6]	Local funds from the City of Houston and Harris County to provide HIV prevention activities.	$1,481,310
CDC (A Portion of Comprehensive STD Prevention Systems) [7]	Provides public health follow-up for the purpose of rapidly locating and referring high-risk individuals to medical examination, treatment, counseling, and risk reduction.	$6,649,763
State Appropriated Funds [8]	Provides counseling, testing and referral, partner services, and evidence-based risk reduction interventions primarily for those at high risk. Supports limited routine HIV testing in medical care settings. Funding comes through the DSHS HIV/STD program and mental health and substance abuse programs (MHSA).	$7,694,673
SAMHSA funds (Federal) [9]	Provides counseling, testing and referral, outreach and education, integrated substance abuse, HIV, and hepatitis prevention efforts. Funding comes from SAMHSA directly to local agencies.	$9,931,985
SAMHSA (State Pass-Through Funds) [10]	Provides counseling, testing and referral, education, and case management. Funding comes through DSHS and directly to local agencies.	$8,022,111
Title X Integration Project for HIV (Federal) [11]	Provides for integration of HIV testing for adults, adolescents, and pregnant women in family planning clinics. Funding comes through DSHS.	$911,000
Total		$69,887,795

HIV prevention in Texas is primarily focused on testing, brief individual counseling, and behavioral interventions with evidence of effectiveness in reducing HIV risk behaviors. These behavioral interventions are delivered to individuals, in groups, or communities. The interventions are designed to modify knowledge, attitudes, beliefs, self-efficacy, and emotional well-being while reducing risk-taking behaviors.[12]

Partner Services 

Partner services are essential public health activities. The Centers for Disease and Prevention (CDC) recognizes partner services as one of the Eleven Elements of Successful Prevention Programs. Based on statewide guidelines, the highest priority for partner services is for early syphilis cases and newly identified HIV-positive cases. Next in priority are HIV positives with continued high-risk behavior and latent syphilis cases of unknown duration. Gonorrhea and chlamydia prevention have the lowest priority. 

Partner services begin when a health department disease intervention specialist (DIS) receives a report of an infected client through the public health surveillance system. The DIS locates and notifies these individuals of their HIV or syphilis infection. The DIS interviews the individual for names and contact information of sexual and needle-sharing partners, refers the patient to additional medical and social services, and provides counseling on methods to reduce the risk of acquiring or transmitting STDs and HIV in the future. Through field investigation, the DIS locates and refers named partners for examination, treatment, and/or counseling. This cycle continues with the identification of each infected partner. 

DSHS funds disease intervention activities through its regional programs and contracts with local health departments. In the fiscal year 2010, eight city and county health departments received funds to carry out these duties in Texas. Those departments are Austin/Travis County Health and Human Services Department, Corpus Christi-Nueces County Public Health District, City of El Paso Department of Public Health, Tarrant County Public Health, Galveston County Health District, San Antonio Metropolitan Health District, Houston Department of Health and Human Services and Dallas County Department of Health and Human Services (Table 4).

Table 4. Local Health Departments funded to conduct Partner Services

Name of Contractor	FY 2011  Contract Total
Dallas County	$1,438,213
Houston	$1,594,701
Tarrant County	$334,203
Austin/Travis County	$196,502
San Antonio Metro	$407,806
Corpus Christi	$39,923
El Paso	$92,160
Galveston	$114,968
Total	$69,887,795

Funding Resources for Hepatitis Prevention and Treatment Services 

Table 5 below provides a summary of estimated federal, local, and state funds currently appropriated, awarded, and/or spent on hepatitis prevention and care services in Texas. It does not include Medicare or Veterans Administration expenditures, nor does it include full accounting for local funds for outpatient care. It does not include expenditures made in correctional facilities, as these were not possible to disaggregate from all healthcare expenditures made in these facilities. 

Table 5. Summary of Hepatitis Prevention and Treatment Resources in Texas

Type of Funds	Service Description	Amount
Hepatitis Treatment and Care Services	Hepatitis Medicaid expenditures for outpatient care and outpatient hospital expenditures.	$28,062,347
Hepatitis Prevention	CDC funding for viral hepatitis coordination was given to DSHS and the City of Houston. Local funds from the City of Houston. SAMHSA funding for hepatitis prevention services.  The majority of these funds (over $3 million) are not dedicated solely to hepatitis prevention. They support integrated substance abuse, HIV, and hepatitis prevention efforts. We include them here rather than in HIV funding because they are almost the only funding with a grant focus that includes hepatitis prevention.  CDC funding for hepatitis A and B immunizations.	$3,453,738
Total		$31,516,085

Funding Resources for Hepatitis Care and Treatment Services 

There is incomplete information on how non-Medicaid recipients receive care for chronic hepatitis. The true extent of caring for those individuals with acute or chronic viral hepatitis needs further study. 

Table 6. Funding Resources for Hepatitis Related Care and Treatment in Texas

Type of Funds	Service Description	Amount
Medicaid (Federal and State) [14]	Provides outpatient medical services and hepatitis-related drugs from Medicaid programs.	$28,062,347

Most people infected as adults recover fully from hepatitis B, even if their symptoms are severe. Hepatitis B-infected persons should be evaluated by a physician for liver disease. Treatment of chronic hepatitis includes the use of antiviral medication including interferon, lamivudine, entecavir, telbivudine, and Adefovir dipivoxil. A liver transplant is also an option if liver damage is severe.[15] Further study of Texas’ health service delivery systems is needed to understand how services are provided to individuals living with chronic viral hepatitis.

Funding Resources for Hepatitis Prevention 

Table 7. Funding Resources for Hepatitis Prevention in Texas

Type of Funds	Service Description	Amount
CDC (Federal) [16, 17]	Funds support viral hepatitis coordination activities at state and local levels. Funds go to DSHS.	$92,751
	Funds support viral hepatitis coordination activities at the local level. Funds go to the City of Houston.	$87,485
SAMHSA [18] (Federal)	These funds are not dedicated only to hepatitis prevention; they support integrated substance abuse, HIV, and hepatitis prevention efforts. They are included here rather than in HIV funding because they are almost the only funding with a grant focus that includes hepatitis prevention. Funds support outreach and educational activities and testing, counseling, and referral services. Funds go directly to local communities.	$1,135,333
CDC [19] (Federal)	These funds include adult hepatitis B and hepatitis A/B vaccines administered through DSHS immunization sites.	$2,138,169
Total		$3,453,738

Prevention Efforts for Hepatitis A Virus 

Texas students in pre-kindergarten and childcare facilities must have hepatitis A virus (HAV) immunizations in all counties. In 40 Texas counties, students must have the HAV vaccine for entry into kindergarten through third grade. DSHS provides the HAV vaccine for adults through DSHS Health Service Regions, local health departments, Texas Youth Commission State School, and other providers. DSHS’ effort to provide HAV vaccine through regional health departments, local health departments, and other agencies is part of a safety net of vaccines for uninsured or underinsured adults at high risk.[20]

Hepatitis B Virus Vaccination of Children 

The best method of preventing infection from hepatitis B is vaccination. DSHS operates the Texas Vaccines for Children (TVFC) Program through participation in the Federal Vaccines for Children Program (VFC) initiated through the Omnibus Reconciliation Act of 1993. Currently, there are over 6,000 providers enrolled in the program. Vaccine is provided to enrolled TVFC providers at no cost for eligible children. The provider may not charge for the vaccine itself but may charge a reasonable administration fee. Hepatitis B virus (HBV) is a required immunization for a student before entry, attendance, or transfer to a child-care facility. The same applied to public or private elementary or secondary schools in Texas. The three-dose vaccination series for HBV is recommended at birth, at one month, and after six months. If the mother has HBV, HBV immune globulin (HBIG) is also administered with the vaccine.[21]

According to the 2009 National Immunization Survey, a random telephone survey conducted by the CDC, 69.8 percent of Texas children have received three doses of HBV vaccine by 35 months of age. The Healthy People 2010 goal is 90 percent.[22]

Adult HBV Vaccination 

Hepatitis B can spread through having unprotected sex, sharing needles and syringes, having contact with blood or open sores, sharing razors, toothbrushes, and washcloths, and using unsterilized needles in body piercing/tattoos. Although school-age children are required to be vaccinated, adults are only required if they are in health-related courses with direct patient contact in institutions of higher education. The highest rate of disease occurs in those 20-49 years old. The Hepatitis B vaccination is recommended for all adults in the following settings: STD treatment facilities; HIV testing and treatment facilities; facilitates providing drug abuse treatment and prevention services; healthcare settings targeting services to Injection Drug Users (IDU) or Men Who Have Sex with Men (MSM); correction facilities; end-stage renal disease programs and facilities for chronic hemodialysis patients; and institutions and nonresidential daycare facilitates for persons with developmental disabilities.[23]

Some students enrolled in higher education are required to either complete a three-dose series of Hepatitis B vaccines or show evidence of immunity before the start of direct patient care. This applies to all medical interns, residents, fellows, nursing students, and others who are being trained in medical schools, hospitals, and health science centers and students attending two-year and four-year colleges whose course work involves direct patient contact regardless of the number of courses taken, the number of hours taken and student classification. Vaccination must occur before any direct patient contact that may be part of the course of study. Also, students enrolled in schools of veterinary medicine whose coursework involves direct contact with animals or animal remains must receive a completed series of HBV vaccines before contact. HBV vaccine is available through local health departments as part of a safety net for uninsured students. 

Local health departments (LHD) are also responsible for planning and implementing efforts to increase awareness of adult immunization recommendations. LHDs collaborate with DSHS health service regional staff and provide information and education on adult vaccination and vaccine-preventable diseases to healthcare providers and the general public. They act as health subject matter experts for providers about vaccination schedules, high-risk groups, recommendations, and disease prevention. Also, the LHDs often collaborate with community organizations, healthcare facilities, local employers, and others to identify populations and individuals who need immunizations. 

The Regional Health Screening Program operates primarily with funds from the Office of Refugee and Resettlement in the U.S. Department of Health and Human Services Administration for Children and Families. The program supports LHDs in principal refugee resettlement areas with resources to provide health assessments to newly arrived official refugees. The program encourages screening and treatment for tuberculosis, immunization status, intestinal parasites, HBV, as well as identification, education, and referral for other health problems.  

The three major settlement areas of Houston, Dallas, and Fort Worth combined receive about 85 percent of all refugee arrivals to Texas. Smaller numbers of refugees settle and receive services from local programs in areas such as Amarillo, Austin, Abilene, and San Antonio.

Perinatal Hepatitis B 

Texas law requires that providers and hospitals screen all pregnant women for HBsAg at their first prenatal visit and at delivery. Perinatal HBV infections and all positive HBsAg mothers must be reported to DSHS (Texas Administrative Code Title 25, Part 1 Chapter 97, subchapter A, § 97.135 and 97.3). 

CDC estimates that there are up to 1,200 children born to HBsAg-positive women every year in Texas. The goal of DSHS’ Perinatal Hepatitis B Prevention Program (PHBPP) is to identify these women so that the newborn can be treated at the time of birth. The program ensures that infants of HBsAg-positive pregnant women receive HBV immune globulin (HBIG) and the HBV vaccine at birth and that they subsequently complete the HBV vaccine services and serological testing. Ninety percent of babies born to a positive mother will become chronic carriers of the disease if they do not receive this treatment at birth. Finally, the program identifies the mother’s contacts and household members to provide immunization, serological testing, and education services as needed.

Prevention Efforts for Hepatitis C Virus 

There is no vaccine to prevent Hepatitis C virus (HCV) infection. Prevention efforts rely on risk assessment, HCV testing, referrals to treatment for those with HCV, and health education. Persons at risk for HCV may also participate in HIV prevention programming designed to reduce health risks associated with injection drug use. Grants provided through SAMHSA directly to communities throughout Texas focus on the prevention of blood-borne diseases such as hepatitis and HIV. These grants support a wide variety of prevention services which range from health education or outreach services to prevention skills building in substance abuse treatment facilities. SAMHSA funds prevention services through block grants received by the DSHS Community Mental Health and Substance Abuse Program. These funds promote the prevention of HIV and other communicable diseases with a particular focus on hepatitis and especially HCV. 

DSHS supports limited and highly targeted HCV testing through 17 HIV testing contractors. Programs are selected based on the number of injection drug users identified through their HIV testing efforts. These programs use a counseling protocol that includes an assessment of HCV risk. When warranted, HCV testing is offered. Each program must establish referral networks for HCV assessment and treatment, HBV and HAV immunization, drug and alcohol treatment, and substance use counseling. Availability of treatment varies and is often dependent on the local indigent healthcare system. Those who are not eligible for indigent care or who have no access to such care may go without treatment for chronic HCV. However, even if care is problematic, individuals with HCV can benefit from health education. Benefits include learning to avoid factors that can aggravate the effects of HCV infection and increase the chances of developing liver disease, and counseling to support the adoption of behaviors that reduce the risk of transmitting hepatitis to others.

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[1] Source of Data: Federal Fiscal Year 2010 data was the most current information available from the HRSA website for total Ryan White funding. Health Resources and Services Administration (HRSA) publishes finalized annual costs two years behind the current year. granteefind.hrsa.gov/Search.aspx Retrieved June 29, 2012. 

[2] Source of Data: Outpatient Medicaid data compiled for unmet need and Women Infant Children & Youth (WICY) reports for Federal Fiscal Year 2010. 

[3] Source of Data: DSHS general revenue expenditures for State Fiscal Year 2010. Email from Hien Le, dated 5/31/2012. 

[4] Source of Data: Housing and Urban Development (HUD) website reported data of Housing Opportunities for People with AIDS (HOPWA) funds allocated as for Federal Fiscal Year 2010. (hud.gov/offices/cpd/about/budget/budget09/index.cfm) Retrieved September 7, 2012. 

[5] Source of Data: Federal fiscal year 2011 grant awards to DSHS for Texas HIV Prevention Services. (Direct funded monies to CBOs, HIV Prevention Projects; Expanded Testing Grant; Enhanced Comprehensive HIV Prevention Planning and Implementation for MSA; PCSI; HIV/SIDS Surveillance & Supplemental; Enhanced Perinatal HIV/AIDS Surveillance; Medical Management Project; and NHBS) and the Funding Summary for Houston Department of Health and Human Services (HIV Surveillance; HIV Prevention Projects; Expanded Testing Grant; Enhanced Comprehensive HIV Prevention Planning and Implementation for MSA. Data also retrieved from CDC funding website on June 29, 2012 cdc.gov/hiv/topics/funding/state-awards/ 

[6] Source of Data: City of Houston General Fund and Harris County RW Part A. Email R. Valdez 8/18/2011. 

[7] Source of Data: DSHS federal grant awards for federal fiscal year 2010 for STD including HIV prevention services (STD Prevention Program Fund). Notice of grant award amended dated 11/28/2011. 

[8] Source of data: DSHS general revenue expenditures for State Fiscal Year 2011. Includes GR expended from substance abuse programs and HIV/STD programs. Email from Sue Gallego, dated 6/19/2012 Email from Hien Le, dated 5/31/2012. 

[9] Source of data: NGA MAI-TCE Funding 9/28/2011. Substance Abuse and Mental Health Services Administration (SAMSHA) website reported the most current data available from funds allocated in state fiscal year 2010 (samhsa.gov/Statesummaries/detail/2010/TX.aspx) Retrieved May 7, 2012. 

[10] Source of data: DSHS federal funds from SAMSHA Block Grant reports based on the state fiscal year 2012 and used for HIV prevention services. Email from Sue Gallego, DSHS MHSA, 6/19/2012. 

[11] Source of data: Title X HIV Integration Spreadsheet itemizing federal funds expended on HIV prevention services for the federal fiscal year 2009. Email from Alicia Nelson, Preventive and Primary Care Unit, 5/24/2012. 

[12] Texas Department of State Health Services. (2006) HIV/STD Program Annual Report 2006. Austin, Texas 

[13] Source of data: Base funding amount awarded to these local health departments in FY 2011 contracts. 

[14] Source of Data: The Medicaid products that are included in this number are: STAR+PLUS, STAR, FFS-PCCM, Vendor Drug and CHIP. Prepared by the HHSC, 7/8/2011. 

[15] Texas Department of State Health Services. The ABC’s of Viral Hepatitis. Retrieved July 1, 2008 from /idcu/disease/hepatitis/resources/hepabc.pdf 

[16] NGA from the CDC for 2011. Issue date 8/6/2012. 

[17] Reported by the City of Houston Health and Human Resources for FY 2010. Email from Tamara Brickham 8/18/2011. 

[18] Substance Abuse and Mental Health Services Administration (SAMSHA) website reported the most current data available from funds allocated in state fiscal year 2011 (samhsa.gov/Statesummaries/detail/2010/TX.aspx) Retrieved 5/7/2012. 

[19] Reported from DSHS Immunization Program for FY 2009 (1/1/09 – 12/31/09), 6/11/2010. 

[20] Texas Department of State Health Services. (2008). Adult and Adolescent Immunization Information. Retrieved July 1, 2008 from /immunize/adult.shtm 

[21] Texas Department of State Health Services. (2007) Texas Vaccines for Children Fact Sheet. Retrieved July 1, 2008 from /immunize/tvfc/. 

[22] Morbidity and Mortality Weekly Report (MMWR) Centers for Disease Control and Prevention, National, State, and Local Area Vaccination Coverage Among Children Aged 19-35 Months- United States 2009; September 17, 2010 / 59(36);1171-1177 cdc.gov/mmwr/preview/mmwrhtml/mm5936a2.htm?s_cid=mm5936a2_w 

[23] Centers for Disease Control and Prevention. (2007) Hepatitis B: Fact Sheet. Retrieved July 1, 2008 from cdc.gov/ncidod/diseases/Hepatitis/b/fact.htm