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EVALUATION OF TEXAS HEALTH SERVICES

Evaluation of Availability of Sexual Health and Substance Use Services in Texas and

Association with HIV Incidence 2022 Report

Carla N. Noreen

Department of Public Health, Baylor University

Epidemiology Capstone

Capstone Committee members:

Dr. Emeka Okafor, PhD, MPH (Faculty advisor)

Dr. Liang Wang, MD, DrPH, MPH (Committee member, Capstone coordinator)
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Executive Summary

HIV/AIDS remains a critical public health concern in Texas as 2019 reports showed a

15% increase over the past 5 years of people with HIV (PWH) with approximately 97,844

Texans having HIV (DSHS 2019-c). The size of the state, lack of receipt of sexual health

services and decreased health access poses a great risk to increased HIV rates across Texas

populations (Tabler et al., 2019). This study aims to provide information on the availability of

STD, HIV, PrEP, and opioid services in all 254 counties of Texas and whether presence of these

services is associated with HIV incidence. Median household income and population size are

hypothesized to be sociodemographic variables that affect HIV incidence and are therefore

evaluated as potential confounders. Data on availability of linear STD, HIV, PrEP, and opioid

services as of 2022 was compiled across the 254 counties in Texas. The data collected showed

133 of 254 counties did not have sexual health services (STD, HIV, PrEP, and opioid). Linear

regression models were used to assess relationships between presence of these services in the

county and HIV incidence adjusting for county level income and population size. The results of

this study showed counties with HIV services (compared to counties without) was associated

with a 28.4% lower HIV incidence while counties with STD services showed a 26.2% lower

incidence of HIV (p=0.0017 and p=0.0049, respectively). This project also developed a visual

map to describe the relationship between HIV incidence across the state and which areas are at

the highest risk. The information collected was translated into an advocacy tool delivered to

government officials working in HIV programs to show the need for expanded services across

the state. An integrative analysis was performed and described the need for collaboration

between local health agencies, state government offices, and community health programs to

empower existing sexual health interventions. Providing resources to community groups allows
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for populations to receive more necessary services and overcome issues of stigma and bias. The

outcome of this project serves as a critical tool in understanding HIV incidence in Texas and the

steps that should be taken to decrease population risk of transmission and increase overall health

and wellness of Texas residents.

Background and Significance

According to 2019 data from the Centers of Disease Control and Prevention (CDC), only

about 83.3% of people with HIV (PWH) in Texas were aware of their status and about 74.6% of

PWH had been linked to care and services (CDC, 2021). This coupled with only about 19.3% of

people being prescribed to Pre-Exposure Prophylaxis (PrEP), a daily medication to prevent

contracting HIV (CDC, 2019). The low percentage of PrEP uptake can be attributed to many

factors including but not limited to decreased awareness, lack of access, and uninsured rates. The

number of individuals receiving PrEP has increased over the past 7 years from 594 users in 2012

to 16,319 in 2019, but the ratio of PrEP users to those newly diagnosed shows that there is still a

portion of the population with unmet needs. The proportion of PrEP users to the number of

people newly diagnosed with HIV (per 100,000 people) is described as the PrEP-to-need ratio

(AIDSVu, 2019). The PrEP-to-need ratio in 2019 was 3.72 with a ratio among females being

1.26, demonstrating the need for further assistance targeting women (AIDSVu, 2019). This can

also be interpreted as in 2019, for every one person newly diagnosed with HIV, there were 1.26

HIV-negative persons using PrEP. The breakdown of 2018 statistics in Texas representing PWH

show that among males, 27% were white, 32% were black, and 36% Hispanic. Among females,

14% were white, 56% black, and 24% Hispanic (DSHS, 2019-c). This is consistent with 2018

nationwide reports of PWH by sex showing that 78.8% of PWH were male while 21.2% were

female (AIDSVu, 2019).

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To promote a well-adjusted life after an HIV diagnosis, early testing is key for Texas

communities. AIDS is the disease that occurs once a case of HIV has progressed beyond the

point of being able to be considered ‘undetectable’. The undetectable status implies the HIV

virus has been limited enough by treatment to where there is no risk of being able to pass the

virus to others. The key to achieving an undetectable status is to catch the virus early and be able

to prescribe treatment. Typically, the length of time between an HIV+ diagnosis and AIDS

diagnosis is long as the hope is to decrease the progression of the disease in time. Although many

initiatives have worked all over the state to alleviate the burden of HIV, 2018 statistics from

Texas showed that 19.5% of new HIV diagnoses were diagnosed late (AIDSVu, 2019). A late

diagnosis is considered to be an any AIDS diagnosis that occurs within three months of receiving

an HIV+ diagnosis (AIDSVu, 2019). In the same year, of the 3,307 individuals newly diagnosed

with HIV, 75.4% of people were linked to care within one month of diagnosis. For the 66,543

individuals living with HIV previously, 76.1% reported receiving medical care for their HIV.

The impact of HIV is felt significantly at the individual level as costs and consistent treatment

make continuous adherence difficult. Previous literature has shown that the need for continuous

treatment among PWH can pose as a barrier for patients, especially considering the estimated

lifetime cost for someone diagnosed with HIV was around $386,000 in 2019 (DSHS, 2019-a).

The burden of HIV in 2018 seemed to increase across age groups as individuals aged 25-34

represent 20.1%, 35-44 are 22.6%, 45-54 are 26.8%, and those 55+ are 26.5% of the total across

Texas (AIDSVu, 2019). The health of the state is of great concern as about 20% of residents

under the age of 65 are without health insurance and the size of the state poses a risk for

vulnerable populations. Opiate and injection drug users are an incredibly vulnerable population

as the drug use heightens the risk of contracting and transmitting HIV as syringes and needles
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may be contaminated (CDC, 2021). In 2018, 6.4% of males and 17.9% of females living with

HIV reported contracting HIV through injection drug use. From the same year, 3.3% of males

and 13.5% of females who were newly diagnosed with HIV reported injection drug use as the

mode of transmission (AIDSVu, 2019). Little information is known on how many people within

Texas use injection drugs or even as estimate of how many have issues with substance use.

While there may not be an accurate estimate of what proportion of the population who uses

injection drugs, the National Survey of Substance Abuse Treatment Services conducted a survey

of Texas in 2019 and reported 512 substance abuse treatment facilities with 35,995 patients

being treated for substance use (NSSATS, 2019). The previous year, deaths related to opioid

overdoses totaled 1,402 at a rate of 4.8 deaths per 100,000 people (CDC, 2020).

It is important when considering the sexual health and wellness of Texans how their

location may help or hinder their ability to seek services, education, and prevention tools. Many

community health interventions exist across Texas but because of the size of the state, the

question remains if residents are able to easily access healthcare. Currently, there is no research

studying what areas of Texas have sexual health and opioid services by county. The size of the

state, lack of receipt of services and decreased health access poses a great risk to increased HIV

rates across Texas populations (Tabler et al., 2019). In many cases, the ease of availability

promotes frequent sexually transmitted diseases (STD)/HIV testing which in turn, increase the

awareness of individuals’ HIV status and prevents passing the infection to others. Availability

and access to HIV treatment services also increases attainment of a HIV viral load undetectable

status after treatment while promoting an undetectable status after treatment (Oppong et al.,

2012). This study aims to fill in the gap found in literature as there is limited information on the
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impact of availability of STD, HIV, PrEP, and opioid services within counties and HIV

incidence in the state of Texas.

Sexual health and wellness are crucial for an increased quality of life and depends on

health-seeking behaviors, education efforts, and resource availability in Texas residents. Because

of this, this study aims to investigate the relationship between the presence of STD, HIV, PrEP,

and opioid services within Texas counties and the HIV incidence rate while adjusting for factors

such as population size and socioeconomic status.

This project aims to provide an extension of original and unique research created during

the MPH practicum. This practicum developed a report evaluating the state county by county and

the subsequent services available to residents but was limited to less than half of all Texas

counties. The current research builds upon this work by incorporating all 254 Texas counties and

further developing insights. This novel area of research is incredibly useful to healthcare

practices and equity of health and wellness across the state. The applied epidemiological

concepts to the project enable the real-life experiences of Texans to be quantified and illustrated

in a manner that expressed the widespread need for increased services and access to healthcare.

Capstone Projects Goals and Objectives

This section describes the capstone goals and objectives aligned with the epidemiology

and public health competencies. The methods used to achieve each goals and objectives are also

included to better understand the process in which the capstone project was completed.

Additionally, the Epidemiological/Public Health competency being fulfilled is connected to each

subsequent goal to demonstrate the way the capstone satisfied the CEPH aligned objective.
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Evidence-Based Approached to Public Health

1. CEPH Learning Objective: Apply epidemiological methods to the breadth of settings and

situations in public health.

Goal 1: To design a research study evaluating service availability by county.

Objective 1: To collect data on all 254 counties using the selected sexual health services.

Each county was evaluated for their sexual health and opioid services available at the time of

data collection. STD and HIV services were included as predictor variables as they were

determined to be the most common sexual health services offered (Tabler et al., 2019). PrEP and

opioid services were added to the predictor variables due to the potential magnitude of

prevention efforts. PrEP medication is a helpful tool in preventing HIV transmission for those

most at risk (CDC, 2019). Opioid services can help provide important assistance to injection-

drug users who may be at risk of contracting HIV through contaminated needles. All four of

these services contribute to the current HIV incidence and therefore are important in

understanding the relationship between HIV risk and available health services.

3. CEPH Learning Objective: Analyze quantitative and qualitative data using biostatistics,

informatics, computer-based programming, and software, as appropriate.

Goal 2: To perform relevant data analysis to evaluate statistically the relationships

between study indicators.

Objective 1: To perform at least 2 different methods of statistical analysis on the

collected data.

Analysis was completed using SAS 9.4 (English) and included Pearson and Spearman

correlation tests and various methods of regression conducive to cross-sectional surveys. The
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learning objective was satisfied through the multiple methods of statistical and epidemiological

analysis to determine the relationships between variables and data collected. This included

describing the distribution of data on income, population, and incidence, describing the

correlation between HIV incidence and population and income, independent sample t-tests,

linear regression between binary and continuous variables, and multivariate analysis on HIV

incidence and service variables with and without confounding variables.

Planning & Management to Promote Health

7. CEPH Learning Objective: Assess population needs, assets, and capacities that affect

communities’ health.

Goal 3: To provide a comprehensive evaluation of all Texas counties using the study

indicators.

Objective 1: To collect data on all 254 counties using the set study indicators.

Each Texas county was evaluated for present services including STD, HIV, PrEP, and

opioid services. County population size (from 2020), median household income (recorded from

2016-2020), HIV incidence (from 2019), and HIV prevalence (from 2019) was also recorded.

The years sampled for these variables represented the most recent recorded data published by

governing entities such as the U.S. Census Bureau and Texas Department of State Health

Services. Capturing the services present from 2021-2022 shows a real-time evaluation of what is

available to residents of Texas. Services available compared to the HIV incidence and prevalence

demonstrates the needs of populations and assets of counties that affect individuals’ abilities to

obtain care when needed.

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Epidemiology Competencies

4. Appraise the ethical foundation for research regulations and connect ethical and legal

principles to the collection, maintenance, use, and dissemination of epidemiologic data.

Goal 4: To use the publishable document as an advocacy package.

Objective 1: To identify at least one Texas government official who operates in a

relevant sphere.

Objective 2: To provide the professional and publishable document to the government

official for advocacy.

A condensed version of the report was created to serve as a form of advocacy for public

health reform and expansion of services across the state. This was targeted to government

officials working in public health programs. The document included graphics that described the

need for communities to have comprehensive sexual health services and how minimized services

affect individuals’ experience when trying to obtain care.

5. Demonstrate ability to manage data sets, design, and execute a data analysis plan, and

draw appropriate inferences from results.

Goal 5: To complete all background research, study design, data collection, data analysis,

and discussion for a comprehensive report.

Objective 1: To create a professional report.

Objective 2: To refine the report into a publishable document.

Objective 3: To apply for publication in at least 1 academic, peer-reviewed journal.

After analysis was completed, interpretations were refined along with the Capstone

advisor, Dr. Okafor. These interpretations were compiled into the results section. Three versions
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of the report were created: a comprehensive Capstone report, a publishable document per journal

guidelines, and a condensed advocacy package. All three versions required different methods of

interpretations to be the most applicable to the public health and political sphere.

Project Related Activities, Methods, and Outcomes

This section outlines the activities completed over the course of the capstone project

along with the methods used to accomplish them. The outcomes of the activities are provided

with the subsequent uses and significance of the deliverables and overall efforts of the research.

Study Design

The capstone was designed as a cumulative learning experience for the MPH graduate

student to apply their interests to a demonstration of public health and epidemiological applied

service. This included working with an existing health program or office. The approach taken for

this capstone was to create a novel research study that focused on a major gap in public health

research. The need for increased health services is understood in public health but there is little

to no data focusing on a state-level. The design of the study was depending on the graduate

student under the advisement of the capstone advisor. Together, a study was created that allowed

the student to develop research in an unprecedented field for a needed health issue. The cross-

sectional nature of the study designed for the project allows for the researcher to examine each

county in Texas and collect information on services available at the time of data synthesis. The

study is designed to highlight sexual health and opioid services under the context of population

size, household income, and HIV incidence/prevalence.

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Data Sources

HIV Incidence

Data for HIV incidence was obtained through the Texas Department of State Health

Services which is comprised of 178 state agencies and provides a variety of public health

services for Texans (DSHS, 2021-a). DSHS has effectively divided Texas into eight health

service regions with major cities in each region functioning as the regional headquarters. The

regional offices within the eight areas of Texas carry many responsibilities but mainly focus on

promoting health services, serving as the local health department for any county without one, and

functioning as the reporting center for Texas health data (DSHS, 2021-b). DSHS performs

regular surveillance on health statistics such as births, deaths, injury, and environmental

concerns. For medical professionals in the state of Texas, illnesses such as COVID-19, anthrax,

Hepatitis A and B, tuberculosis, and other communicable diseases are required to be reported to

DSHS. As for STDs, HIV/AIDS, syphilis, chlamydia, gonorrhea, chancroid, and Hepatitis C are

required to be reported by health care professionals and laboratories (DSHS, 2021-c). DSHS

regional clinics may function as the testing and treatment site for counties without a public health

department, but it should be noted that not all locations have an STD/HIV program.

STD Testing and Services

Each county was examined for an existing health department that offered sexual health

services. If no health department or service was available, an external search was conducted

using a testing site directory. The Youth AIDS Coalition (YAC) is a U.S. based website that

offers STD testing sites and information (YAC, 2021). The YAC works to raise awareness on

sexual health and wellness while providing accessible education. Visitors can use the YAC
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website to find STD testing locations in their area and find information on populations served,

testing offered, hours, fees, and any additional services of the location. The YAC website was

used by researchers to find local programs for STD testing services. Google was used as another

method of searching for services. The search words included the county name, ‘STD’ or ‘STI’,

and ‘services or ‘testing’. The results populated were evaluated for present-day operations and

fulfillment of the variable criteria.

HIV Testing and Services

Information on HIV services in Texas counties came from program websites, Google

searches and recommendations from local clinics. For some counties, clinics and/or health

departments that offered STD testing for HIV but not case management referred patients to local

programs. These were used for the HIV service referral for the specific county being

investigated. In some cases, clinics and health departments did not list any programs for residents

to use for HIV services and therefore Google was used to evaluate what was available in the

county or local area. If no programs were listed through the STD service website, health

department, or Google, local clinics were contacted for recommendations.

PrEP Services

For PrEP services, the DSHS website was used most often as it listed information on

healthcare providers by city that provided prescriptions. If a county was not listed on the DSHS

website, Google searches were conducted to find local providers. In some cases, no clinics in the

county offered PrEP services. In these cases, local STD programs were contacted for

recommendations.
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Opioid Treatment Services

Information on needle and syringe exchange programs in Texas came from the North

American Syringe Exchange Network. The mission of this national network is to connect

individuals to programs and resources aiding substance abuse across the U.S. (NASEN, 2021).

The network highlights syringe exchange programs (SEP) as part of the initiative to expand these

resources to all states, as SEPs are illegal in many areas. This resource was used to find programs

in operation in our sample of counties and investigate all the services offered. As part of our

research was opioid services, NEP programs were evaluated as well.

The U.S. Department of Health and Human Services has organized the Substance Abuse

and Mental Health Services Administration (SAMHSA) (2021). This administration provided a

program directory for opioid treatment and Buprenorphine practitioner locations that is available

to the public through an online website. This directory was used to find opioid use treatment

services and providers operating in the counties in our sample.

Population Size and Median Income

As population size and median household income were included as confounders,

information on these two variables were obtained from the U.S. Census Bureau. The U.S. Census

Bureau developed a helpful tool called “Data.Census”, offering a wide range of data for research

compiled by the U.S Census Bureau (Census Help, 2021). Operating under the U.S. Census

Bureau, the American Community Survey Demographics and Housing 5-Year Estimates of

2016-2020 was used as part of our research. The population estimated were gathered from the

most recent 2020 census from the U.S. Census Bureau.

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Phone Interviews

Phone calls were placed to clinics for information on services. During the calls, staff

provided recommendations for other programs for services not offered by them. This was

especially useful as staff was able to provide information that was not available on their website.

Most notably, staff in a Texarkana clinic (a city on the border of Texas and Arkansas) reported

that they sometimes recommended patients to clinics on the Arkansas side of the city if patients

did not have health insurance or if they needed reoccurring care such as the consistent testing

needed for PrEP prescriptions. Programs were also contacted for information on what year they

began operating in the area to establish a time sequence. HIV incidence data was from 2019 and

therefore it was important to determine when the service began to better understand the results

from analysis.

Data Collection

We began by using the Texas DSHS HIV Surveillance 2019 Annual report produced by

the HIV/STD Epidemiology and Surveillance Branch (DSHS, 2019). This annual report details

HIV/AIDS cases reported to Texas DSHS through the Enhanced HIV/AIDS Reporting System,

eHARS. Using the “HIV Diagnoses by County of Residence, 2010-2019”, cases and rates per

100,000 people were extracted, specifically from the year 2019. Case and rate information from

the report were used as incidence and prevalence data, respectively.

For demographic information, a data set was created using the American Community

Survey Demographics and Housing Estimates of 2019-2020 provided by and operated under the

U.S. Census Bureau. Filters were applied to the data set to only produce information associated
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with the counties being evaluated in our sample. Variables collected from the U.S. Census

Bureau included 2019 population size and 2020 household median income. Two different years

for data was used as the assumption is that the variables did not change significantly between

both years.

Each county was investigated thoroughly for an existing county health department or

health district. All health departments were searched for sexual health and wellness services. If

any services were available, these were included in the county documentation. County health

department websites were also searched for referral information to other services being evaluated

in our research. If none were listed on their website, each department was contacted individually

to acquire information for services recommended to residents by the public health department.

Many counties did not have a public health department or health district. For these counties, the

DSHS website was used to determine whether there was a DSHS clinic operating in the county

that was used for STD testing and treatment. Some counties did not have a DSHS location

nearby and therefore used other programs and services instead. In these cases, Google searches

were conducted for the local health services as well as using the Youth AIDS Coalition website

for STD service locations. All services found were then documented. After listing the service, it

was also recorded whether the service was in the county or not.

Information for needle/syringe exchange programs was gained through NASEP website.

Using their Texas directory, counties included in our evaluation were searched for available

programs as of the year 2021. This was documented along with all other data.

Variables Analyzed

For our purposes, STD services were defined as locations individuals could go for STD

testing, treatment, and/or education. The availability of treatment services was not deemed
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necessary to be considered an STD service as many locations referred their patients to hospitals,

DSHS locations, or other programs to be treated. HIV services were required to offer testing,

treatment, education, and case management. PrEP services were defined as locations that offered

PrEP prescriptions. In some cases, these occurred in the same location as HIV services but in

other counties, individuals needed to go to another location for a PrEP prescription. Opioid

services included any substance abuse assistance or programs for treatment. These services also

included Buprenorphine and Suboxone clinics.

For each county, 10 different variables were thoroughly investigated from a multitude of

resources. The data analyzed included continuous and categorical/binary variables (yes being in

county or no being out of county). The services investigated for all counties were STD, HIV,

PrEP, and opioid. A total SCORE variable was created for each county that counted how many

services were present. The SCORE variable was on a scale of 0-4, (0=no services, 4=all

services).

Data Analysis

Statistical analysis on the gathered data consisted of multivariate regression on the

reported services and incidence level data. First, the yes/no data collected on the presence of

STD, HIV, PrEP, and opioid services in county was converted to a categorical variable. Second,

to prevent possible bias from confounding variables, income and population level variables were

added to the models for adjustment. The addition of population and income variables was used to

adjust for known confounders. Research shows that larger cities were more likely to have sexual

health resources as they had a greater population at risk and in need. We also used household

median income as a socioeconomic status indicator. Previous literature showed that populations
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with a higher income had greater access to sexual education and prevention efforts. Both

variables were included in model building to prevent bias.

Next, linear regression models were constructed to determine the association between the

presence of STD, HIV, PrEP, and opioid services in county and HIV incidence level data. We

log-transformed the HIV incidence data to normalize its distribution. Separate models were

conducted for each service for the association with HIV incidence. Overall F-tests were

completed on each model to obtain the p-value, with a p-value less than 0.05 being considered

insignificant. Because the outcome (HIV incidence) was log-transformed, beta estimates from

the linear regression models, were subsequently exponentiated such that estimates from

predictors could be interpreted as percent increase/decrease in HIV incidence.

Outcome and Results

STD services made up 36.6% of all services offered, opioid services were 34.7%, HIV

services were 33.9% and PrEP services were only 19.3%. This is consistent with previous reports

that showed most counties offered STD testing as the standard and PrEP assistance services were

the least common across the state (Tabler et al., 2019). Table 1 describes the distribution of

services in all counties (see Appendix 1). Overall HIV incidence and prevalence were

determined by the DSHS 2019 HIV Annual Report (2019). According to this report, the overall

HIV incidence in 2019 was 4,203 and prevalence was 14.5 per 100,000 people (DSHS, 2019).

The mean household median income and population size were collected from the U.S. Census

Bureau (Census, 2021). The median income was reported as $63,826 and population size was

29,145,505 (Census, 2021). Of the total 254 counties, 133 counties had no services, 31 had 1

type of service, 21 had 2 types of services, 32 had 3 types of services, and only 37 counties had
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all 4 types of services. Table 1 further illustrates the different combination of services Texas

counties offered at the time of data collection.

Table 1
Demographic characteristics of Texas counties
Total/N %
Overall
Median Income1 $63,826 -
Population Size 2
29,145,505 -
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HIV Incidence3 4,203 -
HIV Prevalence4 14.5 -

STD Services
In-county 93 36.61
None in-county 161 63.39

HIV Services
In-county 86 33.86
None In-county 168 66.14

PrEP Services
In-county 49 19.29
None In-county 205 80.71

Opioid Services
In-county 88 34.65
None In-county 166 65.35

Services Grouped
No services 134 52.76
STD only 4 1.57
HIV only 1 0.39
PrEP only 0 0
Opioid only 26 10.24
STD and HIV 16 6.30
STD and Opioid 4 1.57
HIV and Opioid 1 0.39
STD, HIV, and PrEP 12 4.72
STD, HIV, and Opioid 20 7.87
STD, HIV, PrEP, and Opioid 37 14.57
1
U.S. Census Bureau, American Community Survey (ACS) and Puerto Rico Community Survey
(PRCS), 5-Year Estimates.
2
U.S. Census Bureau, 2020 Census of Population and Housing
3
Number of new HIV cases in Texas. DSHS. (2019). Texas HIV Surveillance Report.
4
Rate per 100,000 people

To better understand the relationship between the confounders, population and income,

and HIV incidence, correlations were completed using a nonparametric test. Due to the abnormal

distribution of HIV incidence, a nonparametric test was essential as it would illustrate the data

clearly.
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To overcome the abnormal nature of the data and show the magnitude of present services

on HIV incidence while adjusting for confounders, regression models were run using natural log

estimates. HIV incidence was transformed to its natural log form. The exponentiated betas and

confidence intervals are described in the Figure 1 forest plot (see Appendix 2). These estimates

were also converted to percentages to be easily understood as percent increase/decrease in HIV

incidence associated with the respective predictors of interest. Counties with HIV services show

a 28.4% lower incidence in HIV while counties with STD services showed a 26.2% lower

incidence of HIV (p=0.0017 and p=0.0049, respectively). These models were run with the

confounders, population and income, and show the presence of services in county can make a

significant different on overall HIV incidence.

Figure 1
Results from adjusted linear regression models of percent increase/decrease in HIV incidence
associated with respective predictors
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Opioid

PrEP

STD

HIV

-45% -35% -25% -15% -5% 5% 15%

Percent Decrease Percent Increase

HIV Incidence

N=254 Counties
Each model was adjusted for income and population
Results are from separate models for each predictor

This echoes research that prompts for service expansion to allow counties to serve a

greater population and make efforts towards decreasing overall HIV prevalence. The information

gathered is incredibly useful as it shows the magnitude of sexual health services in communities

of varying population size and median household income. Table 2 shows the exponentiated betas

and confidence intervals of each variable and further demonstrates the significant need for more

services to combat rising HIV incidence in Texas (see Appendix 3).

Table 2
Exponentiated betas and confidence intervals of variables and covariates
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Variable Beta % CI % CI P
STD 0.74 -26.2 0.6-0.9 (-40.3, -8.8) 0.0049*
HIV 0.72 -28.4 0.6-0.9 (-41.9, -11.8) 0.0017*
PrEP 0.35 -10.7 0.7-1.1 (-29.4, 13.0) 0.35
Opioid 0.84 -16.1 0.7-1.0 (-32.2, 3.8) 0.11
N=254 Counties
Each model was adjusted for income and population
Results are from separate models for each predictor

In summary, the study has the following key findings: 1) the presence of STD services in

counties reduces HIV incidence, 2) the presence of HIV services in counties reduces HIV

incidence, 3) over half of all counties (52.76%) do not have any STD, HIV, PrEP, or opioid

services. The analysis performed during the study supports previous literature that cites program

expansion as a necessary step to overcoming high risk of HIV transmission in Texas. By offering

more services around the state, education and community awareness can also be targeted. Of the

confounders analyzed, population size is the most significant determinant in HIV incidence.

This study has some limitations. First, it is important to note that due to the cross-

sectional nature of the study, data does not show whether the availability of services increased

HIV incidence or if more services are concentrated in areas where HIV incidence is already high.

This would require further observational and longitudinal research that can determine the causal

relationship between HIV incidence and the analyzed confounders. Second, the SCORE variable

was not weighed and therefore interpretations were difficult. A score of 1 was not representative

of which single service was present. Future research should weigh the score variable in a manner

that allows for each service to represent its own effect on HIV incidence. For example, a dummy

variable can be created where in the case of a county have only STD services, the score would be

as follows: 0- no services, 1-STD only, 2-opioid only, 3-HIV only, 4-PrEP only, 5-STD+opioid,

6-HIV+PrEP, etc. This would allow for analysis that describes which services make the biggest
23
EVALUATION OF TEXAS HEALTH SERVICES
impact on HIV incidence and how the presence or absence of certain services affects the health

of communities. Third, the data from each county was collected over a one-year period from

2021-2022. Similar studies should examine all counties from the same year to have consistent

data. Additionally, the median household income and population size estimated were obtained

from two different years. If possible, these should be from the same year of county examination.

A consideration for future research would be to focus on community-specific STD/HIV

programs. This would include initiatives focused on Hispanic/Latino, LGBT+, and African

American populations. Understanding the quality of services for these groups is important as

research shows these populations are at high-risk of HIV and need specialized services (Tabler et

al., 2019). While there were limitations present over the course of this study, many aspects of the

research show strength. First, this study provides information to an area of research that lacks

understanding of HIV incidence and service availability by county. The data collected highlights

this gap and provides the foundation for important work to continue. Second, the findings of the

research support the need for program expansion as the data shows the presence of services in-

county decreases HIV incidence.

In total, the snapshot in available services this study examined shows there is a

significant relationship between the presence of services and HIV incidence across Texas

counties.

GIS Mapping

An additional tool used in this study was the use of Geographic Information Systems

(GIS). ArcGIS PRO was used to visually describe the distribution of HIV incidence across Texas
24
EVALUATION OF TEXAS HEALTH SERVICES
and the corresponding counties. This visual map in Figure 2 is conducive to a better

understanding of the unequal distribution of high-risk areas (Appendix 4).

Figure 2
Map of Texas counties and HIV incidence

HIV Incidence

N=254 Counties

Advocacy

A summary of the findings was provided to Texas Governor Greg Abbott, Representative

Toni Rose from District 110, U.S. Congresswoman Eddie Bernice Johnson representing the 30th

Congressional District of Texas, and Imelda Garcia, MPH of the DSHS. Governor Greg Abbott

has created the Healthier Texas initiative working to expand healthcare across the state. Both

Representative Rose and Congresswoman Johnson have worked to raise awareness and bring

funding to HIV/AIDS programs. Garcia is the associate commissioner of the DSHS Division for

Laboratory and Infectious Disease Services where she oversees the STD/HIV program. All
25
EVALUATION OF TEXAS HEALTH SERVICES
individuals were sent a memo highlighting the results of the findings to serve as a form of

advocacy for sexual health services expansion (Appendix 5). The memo also included an

infographic visually summarizing the study (Appendix 6).

Integrative Analysis

This section provides an integrated discussion covering the background and significance,

proposed goals and objectives, and observations made over the course of the research. The

connected MPH foundational competencies are provided as a context to the discussion.

 
Evidence-Based Approaches to Public Health  

Research concerning HIV cases and sexual health resources (such as STD

testing/treatment, education, HIV prevention medication, etc.) are limited in the state of Texas

(Tabler et al., 2019). Current efforts on a state level partly fall upon the Texas Department of

State Health Services (DSHS) which coordinates a yearly review of HIV/AIDS incidence and

prevalence (DSHS, 2019-a). The information is compiled from health care institutions’

mandatory reporting for new cases of HIV/AIDS. Typically, public health departments offer

sexual health services to residents, but our research showed some areas of Texas having no

health departments. In these cases, DSHS provides sexual health resources to residents. These

DSHS locations are not in every county and depending on their location, require people to travel

outside of their county to receive services. The lack of population-level data leaves a major gap

in understanding the needs of the Texas population. The adverse effects of this lack of

understanding are potentially heightened when considering the rates of coinfection (diagnosis of

more than one infection at a time) are increasing in the northern region of Texas (Barnes et al.,

2019).
26
EVALUATION OF TEXAS HEALTH SERVICES
Risk is increased by not only coinfection but also the availability of what is known as

‘partner services’, or services for HIV+ individuals and their partners, who may or may not also

be positive (Song et al., 2017). These types of services are recommended by the CDC as they are

found to be a more cost-effective approach to community health and wellness and work to help

not only those that are positive but also those most at risk of contracting HIV (Song et al., 2017).

Research has shown that STD/HIV testing rates across populations are reflective of the

availability of services and the length of time a service has been present (Song et al., 2017). This

further demonstrates the need for an expansion of services across the state as well as additional

research on the experience residents have when accessing care. To better understand the needs of

the population, future research should compare HIV incidence to services present during the year

of data collection. Information must be obtained to determine the level of adequate services

offered in each county of the state. The environment of services is crucial in understanding

service usage and accessibility.  The type of information listed above in combination with

incidence and prevalence across the state can better demonstrate the experiences of individuals at

risk of contracting HIV.  Not only does this provide more information on the obstacles and

opportunities for care for HIV+ and at-risk people, but it also shows state programs where the

greatest impact can be made on HIV rates in communities.

Public Health & Health Care Systems 

As stated above, an integration of community services and an understanding of county

incidence and prevalence is needed to promote adequate availability of HIV-reducing

services. County public health departments are tasked with offering sexual health services but

due to finances, resources, staffing issues, etc., some departments are unable to offer STI/HIV
27
EVALUATION OF TEXAS HEALTH SERVICES
testing. Needed services must be outsourced and community health programs should be

empowered to continue helping when a department is unable to.  

Some community health programs in Texas target specific at-risk populations. This type

of specialized efforts is important as studies show rates and risk of HIV infection are not

consistent across all gender and racial demographics. Theoretical and practical health studies

have shown multiple inequalities (gender, sexual orientation, minority status, etc.) heighten HIV

risk (Fish et al., 2016). Research in the U.S. show one out of every two African-American and

one out of every four Latino gay, bisexual, and men who have sex with men (GBMSM) will be

diagnosed with HIV compared to their white counterparts (Schnarrs et al., 2018). These types of

studies point out the need for services to be geared towards a minority status or sexual

orientation. The same 2018 study showed the perceived risk and social stigmas associated with

HIV testing and PrEP use is an issue among GBMSM. In Texas, the ‘multiple marginalization’

issue is expounded as regions on the U.S.-Mexico border suffer a critical vulnerability to

decreased access to care, limited sexual health knowledge, and high-risk sexual behavior (Tabler

et al., 2019). A significant proportion of Texas residents are at a heightened risk of contracting

HIV due to their location, race, sexual orientation, community beliefs, and minority status. This

issue can be tackled through specialized awareness and education efforts that target social

stigmas and biases that are widely held in these populations.

Health care and public health efforts must integrate to offer a well-rounded and

comprehensive approach to HIV rates in Texas. The Hispanic/Latino, African American, and

LGBT+ communities require specialized health programs that provide relevant information that

fits their lifestyle. Socially relevant sexual health education can help prevent HIV/STD risk and

increase PrEP-uptake for individuals who are in the most need. Doing so on a community level
28
EVALUATION OF TEXAS HEALTH SERVICES
can potentially curb the health-hindering stigmas and biases that prevent frequent testing and

PrEP-uptake that is being seen. County departments that are unable to provide services should

offer local resources that highlight these community groups and thus empower the actions being

done by community health programs. While there may be many logistical reasons as to why

county departments are not able to offer services (such as financial constraints, staffing issues,

etc.), residents should still have access to information that allows them to reach out to local

resources and take the necessary steps to receive care.

 
Planning & Management to Promote Health 

Current programs offering specialized sexual health resources for those in need provide

amazing and useful tools for people to feel empowered about their health. In Texas, the Valley

AIDS Council provides services to areas at the U.S.-Mexico border and El Paso (Tabler et al.,

2019). This type of program relied on grant funding to provide services to minority groups at the

greatest risk of transmission. A key part of the functioning of this program is the community

mobilization and collaboration with the South Texas Equality Project (STEP) and Texas

Department of State Health Services (Tabler et al., 2019). The Valley AIDS Council is not only

the specialized program. The Houston area has a radicalized movement of collaboration between

community members, activities, and public health professionals (Abbas et al., 2020). Increased

usage of the Ryan White CARE funding allows more people to be connected to necessary

services. The Ryan White HIV/AIDS Program (RWHAP) is the largest HIV-focused initiative

administered by the U.S. Department of Health and Human Services, Health Resources and

Services Administration and HIV/AIDS Bureau (Ryan White HIV/AIDS Program, 2022). The

RWHAP funds HIV services for low-income HIV+ individuals and grants funding to cities,

states, counties, and community health programs that work to provide HIV medical care and
29
EVALUATION OF TEXAS HEALTH SERVICES
support services, aim to improve the health outcomes PWH, and reduce transmission rates of

HIV (Ryan White HIV/AIDS Program, 2022).

Enhancing these efforts and empowering the connected communities depends on

additional funding from state and national levels. Evaluation of the impact of these community

health programs can add to the research that supports specialized sexual health programs and

potentially increase funding. The empowerment of these interventions requires increased

funding, social support, and community awareness. Partnership development can expand the

reach of the effective programs already in place and bridge the gap between community

empowerment and local legislation.

Policy in Public Health 

As discussed, the Texas DSHS provides community support where there is no public

health department. In these instances, clinics may be sporadically placed and are not centralized

to high-risk areas. While these clinics help the surrounding areas significantly, there is a need for

expansion of DSHS sexual health clinics as the distance between clinics is an impediment to

community health. Location expansion is not the only way more people can be helped. As

discussed earlier, additional funding for existing community health programs can serve as a

significant way for populations to be empowered. In these cases, community connections are

strengthened, and residents are supported by government offices and legislation to support one

another. Medicaid expansion is another method to support the most vulnerable. Texas is among

the states that have not expanded the state-federal program leaving 17.7% of residents uninsured

(Abbas et al., 2020). Medicaid can offer important sexual health services such as testing,

treatment, and PrEP prescriptions. These types of services can help decrease the disparity across
30
EVALUATION OF TEXAS HEALTH SERVICES
the population and prevent an increase in HIV transmission. Considering recent changes in

healthcare policy allow for PrEP prescriptions to be free under all insurance, increased rates of

insurance enrollment can make a significant impact on those most at risk (Ryan, 2021). PrEP

medication does not just need a prescription from a health provider but also requires consistent

blood testing to monitor the health of the individual. The frequent blood testing is another cost

that cannot be afforded by uninsured individuals. Assistance such as Medicaid can allow people

access to the frequent care to increase their health and reduce the risk of transmission.

Overcoming the issue of HIV in Texas can be approached through many avenues. Service

accessibility, community awareness, increased education efforts, social support to existing

programs, policy reform for Medicaid expansion and county-level research are all important

steps to take to prioritize the health of Texas residents.

Systems Thinking 

Systems thinking can be thought of as the way information, professionals, resources,

processes, and technology can work together to minimize the gap in health inequalities. Using

this type of approach can help identify the critical issues in health across a population as well as

point out the opportunities for improvement (Trbovich, 2014). When talking about the issue of

HIV in Texas, systems thinking is crucial in understanding how current and previous efforts have

failed and where the potential for improvements lay. As discussed, many community health

programs are tasked with relying on internal resources and federal grants to provide services. A

systems thinking approach illustrates how a collaboration between DSHS, local health

departments, government agencies, and community organizations can understand the complex

relationship between HIV incidence and prevalence and community resources. Equipping and
31
EVALUATION OF TEXAS HEALTH SERVICES
enhancing the capacity of community organizations is a viable and important way of engaging

individuals with the care they need (Abara et al., 2015). Systems thinking is currently being used

in faith-based organizations in Texas that utilize churches to access vulnerable communities and

provide care free of stigma and bias (Abara et al., 2015). These actions can serve as a model for

not only other faith-based organizations, but also public health institutions and non-faith-based

programs.

The use of systems thinking in public health is incredibly useful as it allows multiple

perspectives and incorporates different fields in expanding care. Health research is an important

part of this as it can help shed light on individual and population-level experiences. The report

provided by this research can offer population-level data, but the addition of individual level

experiences can show the significant need for a targeted approach on multiple levels of the

socioecological model of health.

32
EVALUATION OF TEXAS HEALTH SERVICES
References

Abara, W., Coleman, J., Fairchild, A., Gaddist, B., & White, J. (2015). A Faith-Based

Community Partnership to Address HIV/AIDS in the Southern United States:

Implementation, Challenges, and Lessons Learned. Journal of Religion & Health, 54(1),

122–133. https://doi.org/10.1007/s10943-013-9789-8

Abbas, U. L., Hallmark, C. J., McNeese, M., Hemmige, V., Gathe, J., Williams, V., Wolf, B., &

Rodriguez-Barradas, M. C. (2020). Human Immunodeficiency Virus in the State of Texas

of the United States: Past Reflections, Present Shortcomings, and Future Needs of the

Public Health Response. Open Forum Infectious Diseases, 7(10), ofaa348.

https://doi.org/10.1093/ofid/ofaa348

Barnes, A., Jetelina, K. K., Betts, A. C., Mendoza, T., Sreeramoju, P., & Tiro, J. A. (2019).

Emergency Department Testing Patterns for Sexually Transmitted Diseases in North

Texas. Sexually Transmitted Diseases, 46(7), 434–439.

https://doi.org/10.1097/OLQ.0000000000001003

Census Help. (n.d.). Retrieved August 3, 2021, from

https://ask.census.gov/prweb/PRServletCustom/app/ECORRAsk_/YACFBFye-

rFIz_FoGtyvDRUGg1Uzu5Mn*/!STANDARD?

pzuiactionzzz=CXtpbn0rTEpMcGRYOG1vS0tqTFAwaENUZWpvM1NNWEMzZ3p5a

FpnWUxzVmw0TjJoRFIyaHRNOEVSbkxSWTExeFRTa2Vv*#

DSHS. (n.d.-a). Data & Surveillance. Texas Department of State Health Services. Retrieved

August 3, 2021, from https://www.dshs.state.tx.us/data-surveillance/

33
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DSHS. (n.d.-b). Texas Department of State Health Services, Public Health Regions. Texas

Department of State Health Services. Retrieved August 3, 2021, from

https://www.dshs.state.tx.us/regions/default.shtm

DSHS. (2019). Texas HIV Surveillance Report. 32.

Fish, J., Papaloukas, P., Jaspal, R., & Williamson, I. (2016). Equality in sexual health promotion:

A systematic review of effective interventions for black and minority ethnic men who

have sex with men. BMC Public Health, 16(1), 810. https://doi.org/10.1186/s12889-016-

3418-x

HIV and Substance Use | HIV Transmission | HIV Basics | HIV/AIDS | CDC. (2021, April 21).

https://www.cdc.gov/hiv/basics/hiv-transmission/substance-use.html

NASEN. (2021). North American Syringe Exchange Network | NASEN. NASEN.

https://nasen.org

NSSATS. (n.d.). Retrieved August 15, 2021, from

https://www.samhsa.gov/data/sites/default/files/reports/rpt29397/2019_NSSATS_StPro_

combined.pdf

Ryan, B. (2021, July 21). PrEP, the HIV prevention pill, must now be totally free under almost

all insurance plans. NBC News. https://www.nbcnews.com/nbc-out/out-health-and-

wellness/prep-hiv-prevention-pill-must-now-totally-free-almost-insurance-plans-

rcna1470

Ryan White HIV/AIDS Program. (2022). Ryan White HIV/AIDS Program Legislation | Ryan

White HIV/AIDS Program. Retrieved April 27, 2022, from

https://ryanwhite.hrsa.gov/about/legislation
34
EVALUATION OF TEXAS HEALTH SERVICES
Schnarrs, P. W., Gordon, D., Martin-Valenzuela, R., Sunil, T., Delgado, A. J., Glidden, D.,

Parsons, J. T., & McAdams, J. (2018). Perceived Social Norms About Oral PrEP Use:

Differences Between African–American, Latino and White Gay, Bisexual and Other Men

Who Have Sex with Men in Texas. AIDS and Behavior, 22(11), 3588–3602.

https://doi.org/10.1007/s10461-018-2076-7

Song, W., Mulatu, M. S., Rorie, M., Zhang, H., & Gilford, J. W. (2017). HIV Testing and

Positivity Patterns of Partners of HIV-Diagnosed People in Partner Services Programs,

United States, 2013-2014. Public Health Reports, 132(4), 455–462.

https://doi.org/10.1177/0033354917710943

Tabler, J., Mykyta, L., Schmitz, R. M., Kamimura, A., Martinez, D. A., Martinez, R. D., Flores,

P., Gonzalez, K., Marquez, A., Marroquin, G., & Torres, A. (2019). Social Determinants

of Sexual Behavior and Awareness of Sexually Transmitted Infections (STI) Among

Low-Income HIV+ or STI At-Risk Hispanic Residents Receiving Care at the U.S.–

Mexico Border. Journal of Community Health, 44(1), 127–136.

https://doi.org/10.1007/s10900-018-0562-5

Texas. (n.d.). AIDSVu. Retrieved August 14, 2021, from https://aidsvu.org/local-data/united-

states/south/texas/

Texas DSHS HIV/STD Program—Disease Reporting. (n.d.). Retrieved August 3, 2021, from

https://www.dshs.texas.gov/hivstd/healthcare/reporting.shtm

Trbovich, P. (2014). Five Ways to Incorporate Systems Thinking into Healthcare Organizations.

Biomedical Instrumentation & Technology, 48(s2), 31–36. https://doi.org/10.2345/0899-

8205-48.s2.31
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EVALUATION OF TEXAS HEALTH SERVICES
Personal/Professional Growth and Critique for Future Interns

The design of this capstone project varied form the work of others as the design of a

novel study and research was not performed by my peers. My unique approach to the capstone

project was incredibly difficult as it required a major investment in time and resources to conduct

a study at the level of professionalism I desired. While this project was cumbersome, the lessons

I learned from completing my capstone were valuable and directly applicable to professional life

after graduate school.

The ability to design my own study with little parameters was a new experience. Through

the advisement of my practicum and capstone mentor, I was able to develop research that I felt

passionate about. This passion translated to a deep motivation to develop something unique and

useful for public health and government officials. The capstone project evolved from lessons

learned over the course of my practicum. The initial design of my practicum only allowed a

specific type of application and failed to comprehensively view the issue. The notes and

feedback taken from the practicum inspired change for the capstone that would allow for greater

analysis and wider applicability. Doing so meant I would also need to finesse my skills of data

collection, management, and analysis. These three skills challenged the classroom-level of

experience I had and allowed me to develop a professional level of skill. My understanding of

data analysis was limited prior to capstone but overtime, expanded to methods of statistical

analysis that is routinely used by epidemiologists in the field. Along with the hard skills of data

management, I also developed the necessary skill of writing. My capstone challenged me to not

only write professionally, but also to adapt my information to documents that can be easily

understood by the wider public. This was a useful skill as it challenged me to keep all the key
36
EVALUATION OF TEXAS HEALTH SERVICES
information but present it in a way that describes the significance from a minimally science-

based perspective for anyone to understand.

Over the course of the capstone project, many difficult lessons were learned through

mistakes and hardship. My skills of time management were challenged as the self-led nature of

the project required frequent work overtime. The products developed built off one another and

thus required work to be done in advance and early in the capstone. I would have liked to know

from the beginning the steps needed to effectively accomplish the goals of my capstone. Had I

developed a succinct plan showing each step of my capstone, I would have been able to see what

work needed to be done early on for other things to be accomplished later.

My advice for future interns working on their capstone is to challenge them in their

thinking of what they can do. Instead of limiting their project to what they think they are

qualified to accomplish or what skills they currently have, interns should think big and feel they

have the resources to expand past their classroom skills. I initially felt very limited in what I

could do but soon realized I was only limited by my own thinking. Through the guidance of my

mentor and advisor, I could do things I had never done before and feel confident in the results. It

is daunting to venture into unknown territory in such a large and significant project, but this

should inspire future interns to push the boundaries of their comfort zones and personal

expectations. The work I did over my practicum and capstone prepared me for situations I will

face in my future career and have enabled me to feel capable of doing things I have never done

before effectively. The biggest lesson I have learned from my capstone is to believe in myself

and feel empowered to jump into daunting tasks with curiosity and confidence.
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EVALUATION OF TEXAS HEALTH SERVICES
Appendix 1

Table 1
Demographic characteristics of Texas counties
Total/N %
Overall
Median Income1 $63,826 -
Population Size 2
29,145,505 -
HIV Incidence3 4,203 -
HIV Prevalence 4
14.5 -

STD Services
In-county 93 36.61
None in-county 161 63.39

HIV Services
In-county 86 33.86
None In-county 168 66.14

PrEP Services
In-county 49 19.29
None In-county 205 80.71

Opioid Services
In-county 88 34.65
None In-county 166 65.35

Services Grouped
No services 134 52.76
STD only 4 1.57
HIV only 1 0.39
PrEP only 0 0
Opioid only 26 10.24
STD and HIV 16 6.30
STD and Opioid 4 1.57
HIV and Opioid 1 0.39
STD, HIV, and PrEP 12 4.72
STD, HIV, and Opioid 20 7.87
STD, HIV, PrEP, and Opioid 37 14.57
53
U.S. Census Bureau, American Community Survey (ACS) and Puerto Rico Community Survey
(PRCS), 5-Year Estimates.
2
U.S. Census Bureau, 2020 Census of Population and Housing
3
Number of new HIV cases in Texas. DSHS. (2019). Texas HIV Surveillance Report.
4
Rate per 100,000 people
38
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Appendix 2

Figure 1
Results from adjusted linear regression models of percent increase/decrease in HIV incidence
associated with respective predictors
Opioid

PrEP

STD

HIV

-45% -35% -25% -15% -5% 5% 15%

Percent Decrease Percent Increase

HIV Incidence

N=254 Counties
Each model was adjusted for income and population
Results are from separate models for each predictor
39
EVALUATION OF TEXAS HEALTH SERVICES

Appendix 3

Table 2
Exponentiated betas and confidence intervals of variables and covariates
Variable Beta % CI % CI P
STD 0.74 -26.2 0.6-0.9 (-40.3, -8.8) 0.0049*
HIV 0.72 -28.4 0.6-0.9 (-41.9, -11.8) 0.0017*
PrEP 0.35 -10.7 0.7-1.1 (-29.4, 13.0) 0.35
Opioid 0.84 -16.1 0.7-1.0 (-32.2, 3.8) 0.11
N=254 Counties
Each model was adjusted for income and population
Results are from separate models for each predictor
40
EVALUATION OF TEXAS HEALTH SERVICES

Appendix 4

Figure 2
Map of Texas counties and HIV incidence

HIV Incidence

N=254 Counties
41
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Appendix 5

*This memo was sent to Texas Governor Greg Abbott, Representative Toni Rose from District
110, U.S. Congresswoman Eddie Bernice Johnson representing the 30th Congressional District
of Texas, and Imelda Garcia, MPH of the DSHS.

To: Representative Name*

From Carla Natalie Noreen, MPH

:

CC: Dr. Emeka Okafor, PhD, MPH (Faculty Advisor) and Dr. Liang Wang, DrPH, MPH (Capstone
Advisor)

Date: 26 April 2022

Re: Evaluation of Availability of Sexual Health and Substance Use Services in Texas and
Association with HIV Incidence

Background
HIV/AIDS remains a critical public health concern in Texas as 2019 reports showed a 15%
increase over the past 5 years of people with HIV with approximately 97,844 Texans having HIV (DSHS
2019). The size of the state, lack of receipt of sexual health services and decreased health access poses a
great risk to increased HIV rates across Texas populations (Tabler et al., 2019). According to 2019 data
from the CDC, only about 83.3% of HIV+ Texans were aware of their status and about 74.6% of HIV+
people had been linked to care and services (CDC, 2021). This coupled with only about 19.3% of people
being prescribed to Pre-Exposure Prophylaxis (PrEP), a daily medication to prevent contracting HIV
(CDC, 2019). It is important when considering the sexual health and wellness of Texans how their
location may help or hinder their ability to seek services, education, and prevention tools. Many
community health interventions exist across Texas but because of the size of the state, the question
remains if residents’ sexual health is being properly cared for. Currently, there is no research studying by
county what areas of Texas have sexual health and opioid services.
This study aims to provide information on the availability of STD, HIV, PrEP, and opioid
services in all 254 counties of Texas and whether the presence of these services is associated with HIV
42
EVALUATION OF TEXAS HEALTH SERVICES
incidence. Each county was evaluated for the presence of a health department that offered sexual health
services. If no department was available, other sources were used to determine if residents had access to
health programs for STD and HIV testing/treatment, PrEP services, and opioid support services.

Critical Analysis
The research conducted showed 134
counties did not have any sexual health
services. Only 16 counties had STD and HIV
services and 37 counties had STD, HIV,
PrEP, and opioid services. The presence of
STD and HIV services is necessary to the
overall health of Texans as my data showed
counties with HIV services had a 28.4%
lower incidence in HIV while counties with HIV Incidence
STD services showed a 26.2% lower HIV
incidence. The data also showed that
population size and median household income
changed the overall HIV incidence for Texas
counties. As part of my research, I created a
map of Texas that describes HIV incidence by
county. This can show areas in the most need of services.

Outcome
The analysis performed during the study supports previous literature that cites program expansion
as a necessary step to overcoming high risk of HIV transmission in Texas. By offering more services
around the state, education and community awareness can also be targeted. Sexual health education and
community awareness for programs available are important pieces towards empowering populations and
overcoming HIV risk. Additional sexual health interventions offering STD, HIV, PrEP, and opioid
services are critical for the health of Texas. HIV/AIDS remains an important public health issue that
needs your support. Leaders like you can make a difference for the health of our great state. If you would
like more information, please reach out to me at Natalie_Noreen1@alumni.baylor.edu or at (817)676-
8106. If you would like access to the full report and additional documentation, please email me or visit
my website natalienoreenmph.weebly.com.
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Thank you

Resources
CDC. (2021). HIV and Substance Use | HIV Transmission | HIV Basics |

HIV/AIDS.https://www.cdc.gov/hiv/basics/hiv-transmission/substance-use.html

DSHS. (2019). Texas HIV Surveillance Report. 32.

Tabler, J., Mykyta, L., Schmitz, R. M., Kamimura, A., Martinez, D. A., Martinez, R. D., Flores, P.,

Gonzalez, K., Marquez, A., Marroquin, G., & Torres, A. (2019). Social Determinants of Sexual

Behavior and Awareness of Sexually Transmitted Infections (STI) Among Low-Income HIV+ or

STI At-Risk Hispanic Residents Receiving Care at the U.S.–Mexico Border. Journal of

Community Health, 44(1), 127–136. https://doi.org/10.1007/s10900-018-0562-5

44
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Appendix 6
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