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Health Department

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

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Health Department

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  1. Riding the WavesSeptember 16 & 17, 2010“Public Health Strategies to Address STDs, HIV & TB in Texas”David Lakey, M.D.CommissionerTexas Department of State Health Services

  2. Texas Department of State Health Services (DSHS) Became Operational on September 1, 2004 Health Department Mental Health Agency Substance Abuse Agency 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. Life Expectancy in TexasTotal and by Race, 1989 - 2007 6

  7. Increased Life Expectancy Driven by Public Health Improvements Increased years due to public health measures: 25 Increased years due to medical care advances: 5 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 7

  8. Impact of Vaccines in the 20th Century

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

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

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

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

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

  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. 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

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

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

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

  19. 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

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

  21. Persons Living with HIV, 1987

  22. Persons Living with HIV, 1997 22

  23. Persons Living with HIV, 2007

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

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

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

  27. 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). Rate of New HIV Diagnoses by Sex & Race / Ethnicity 27

  28. 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

  29. Number of TB Cases Texas 1999-2008

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

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

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

  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. 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 34

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

  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. 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. HIVFunds 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 39

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

  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. 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

  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. 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 45

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

  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. 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 48

  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 49

  50. Texas Center for Infectious Disease (TCID) 50

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