2004 2004 Environmental Environmental

Scan:Scan:Selected Findings Selected Findings Conducted for the Ryan White Planning CouncilConducted for the Ryan White Planning Council

bybyRTH Research Group, LLCRTH Research Group, LLCRoberto Trevino, Ph.D.Roberto Trevino, Ph.D.

Alan Jay Richard, Ph.D.Alan Jay Richard, Ph.D.

Diana Lemos, B.S.Diana Lemos, B.S.

Demographic Demographic TrendsTrends

Age-Adjusted HIV/AIDS Age-Adjusted HIV/AIDS Mortality Rates for Texas Mortality Rates for Texas are Similar to those for are Similar to those for

CaliforniaCalifornia

0

5

10

15

20

25

30

35

1996 1997 1998 1999 2000 2001

TexasCaliforniaFloridaNew York

Texas exhibited less overall Texas exhibited less overall reduction in mortality and greater reduction in mortality and greater

ethnic disparity after the ethnic disparity after the introduction of HAART than introduction of HAART than

CaliforniaCalifornia

-80%

-70%

-60%

-50%

-40%

-30%

-20%

-10%

0%

Texas California Florida New York

OverallAfrican AmericanLatinonon-Latino White

Medical TrendsMedical Trends

Ongoing HIV Clinical Trials Ongoing HIV Clinical Trials by Typeby Type

0

10

20

30

40

50

60

70

80

Number

Acute/ Early Infection

Alternative/ Complementary Medicine

Prevention (mother-childtransmission, behavior, vaccines, etc.Observational

Treatment Experienced (Resistanceor Toxicity)Treatment Interruption

No Prior Treatment

HIV Vaccine ResearchHIV Vaccine Research Since the first HIV vaccine trial enrolled Since the first HIV vaccine trial enrolled

volunteers in 1988, 49 clinical trials of 26 volunteers in 1988, 49 clinical trials of 26 different vaccine candidates have been studied in different vaccine candidates have been studied in clinical trials by NIH clinical trials by NIH

At least 13 different gp120 and gp160 envelope At least 13 different gp120 and gp160 envelope candidates have been evaluated in phase I/II trials candidates have been evaluated in phase I/II trials

Most research has focused on gp120 rather than Most research has focused on gp120 rather than gp140/gp160gp140/gp160

NIH spends the most on vaccines, but not enough NIH spends the most on vaccines, but not enough is being spent in HIV vaccine developmentis being spent in HIV vaccine development

Number of Cases and NIAID Number of Cases and NIAID Research Dollars Spent on Research Dollars Spent on

Anthrax and HIV/AIDS Anthrax and HIV/AIDS Vaccines, 2002Vaccines, 2002

40000

1805000

10000

1500020000

25000

3000035000

40000

Number of Cases

HIV/ AIDSAnthrax

413

1500

0200400600800

1000120014001600

Millions

Spending

HIV/ AIDSAnthrax

Vaccine Trials by Vaccine Vaccine Trials by Vaccine TypeType

0 1 2 3 4 5 6

CanarypoxVEE Vector

ProteinDNA PlasmidAdenovectorsMVA vectors

Heat-Killed Recombinant Yeast

PlannedCurrent

Vaccine Trials by Client Vaccine Trials by Client PopulationPopulation

0

10

20

30

40

50

60

70

Recruiting Closed

HIV Negative(Preventive Vaccines)HIV Positive(Therapeutic Vaccines)

Current Approved Anti-Current Approved Anti-RetroviralsRetrovirals

0

1

2

3

4

5

6

7

8

9

10

Number Approved by FDA

nucleoside analoguereverse transcriptaseinhibitorsnon-nucleosideanalogue reversetranscriptase inhibitorsHIV protease inhibitors

fusion inhibitors

HIV Prevention Trials HIV Prevention Trials Network Studies by Network Studies by Targeted PopulationTargeted Population

0% 17%

66%

17% 0%MSMWomenInfantsCouplesIDU

HIV Prevention Trials HIV Prevention Trials Network Studies by Network Studies by Intervention TypeIntervention Type

29%

14%37%

5%5% 10%

Antiretrovirals

Behavioral

Microbicides

Canarypox Vaccine

Antibiotics

Preparation (Subject Recruitment andRetention)

Funding TrendsFunding Trends

Federal Funding TrendsFederal Funding Trends

Total Federal Funding for HIV/AIDS is a Total Federal Funding for HIV/AIDS is a Small Fraction of the Federal BudgetSmall Fraction of the Federal Budget

Federal funding Continues to Increase butFederal funding Continues to Increase but Increases do not keep pace with the epidemicIncreases do not keep pace with the epidemic Increases are concentrated in mandated Increases are concentrated in mandated

funding categoriesfunding categories Increases Reflect Changing Policy PrioritiesIncreases Reflect Changing Policy Priorities In recent years, increases do not include In recent years, increases do not include

minority services, housing services, prevention minority services, housing services, prevention services, substance abuse services, or mental services, substance abuse services, or mental health serviceshealth services

Federal Funding Trends Federal Funding Trends (Cont.)(Cont.)

Federal funding Continues to Increase butFederal funding Continues to Increase but Funding for Care and Assistance represents a Funding for Care and Assistance represents a

shrinking proportion of all federal fundingshrinking proportion of all federal funding The Minority Initiative, targeting minority The Minority Initiative, targeting minority

groups disproportionately affected by groups disproportionately affected by HIV/AIDS, represents a tiny and shrinking HIV/AIDS, represents a tiny and shrinking fraction of overall HIV/AIDS fundingfraction of overall HIV/AIDS funding

Minority Initiative SAMHSA funding - the only Minority Initiative SAMHSA funding - the only funding from that agency targeting people funding from that agency targeting people living with or at heightened risk for HIV/AIDS - living with or at heightened risk for HIV/AIDS - is estimated to drop dramatically in the 2004 is estimated to drop dramatically in the 2004 budget yearbudget year

Total Federal HIV/AIDS Funding Total Federal HIV/AIDS Funding Increased Steadily, with a More Increased Steadily, with a More

Dramatic Increase Between 2000 Dramatic Increase Between 2000 and 2001and 2001

1997 1998 1999 2000 2001 2002 2003 2004 2005$-

$2

$4

$6

$8

$10

$12

$14

$16

$18

$20

Billions

Meanwhile, the Number of Meanwhile, the Number of Persons Living with Persons Living with

HIV/AIDS Also Continues to HIV/AIDS Also Continues to IncreaseIncrease

0

100000

200000

300000

400000

500000

600000

700000

800000

2000 2001 2002 2003 2004 2005

Total Number ofPersons Living withHIV/ AIDS Living inReporting StatesEstimated TotalNumber of PersonsLiving with HIV/ AIDSLiving in All States

So Spending Per Person So Spending Per Person Living with HIV/AIDS has Living with HIV/AIDS has

Actually Decreased Slightly Actually Decreased Slightly since 2001since 2001

$0.00

$2,000.00

$4,000.00

$6,000.00

$8,000.00

$10,000.00

$12,000.00

$14,000.00

$16,000.00

$18,000.00

$20,000.00

2000 2001 2002 2003 2004 2005

Dollars Per PersonLiving withHIV/ AIDS

Yearly Changes Among Funding Yearly Changes Among Funding Categories Reveal More Shifts in Categories Reveal More Shifts in

PrioritiesPriorities

-40.00%-30.00%-20.00%-10.00%

0.00%10.00%20.00%30.00%40.00%50.00%60.00%70.00%

1999-2000 2000-2001 2001-2002 2002-2003

Care Research Prevention International Housing & Assistance

Starting in 2001, Total HIV/AIDS Starting in 2001, Total HIV/AIDS Funding Increases Began to Outpace Funding Increases Began to Outpace

Increases for Care and AssistanceIncreases for Care and Assistance

$0$2$4$6$8

$10$12$14$16$18

$20

Billions

2000 2001 2002 2003 2004 2005

Total FederalHIV ServicesFunding

Total FederalFunding forHIV/AIDS

Starting this Fiscal Year, the Proportion of HIV/AIDS Starting this Fiscal Year, the Proportion of HIV/AIDS Funding Designated for International Assistance Funding Designated for International Assistance Increases, while the Proportion Designated for Increases, while the Proportion Designated for

Prevention, Cash/Housing Assistance, and Research Prevention, Cash/Housing Assistance, and Research DecreasesDecreases

HIV/AIDS Allocations by Category, 2000-2005

0%10%20%30%40%50%60%70%80%90%

100%

2000 2001 2002 2003 2004 2005

Fiscal Year

Perc

en

t o

f T

ota

l H

IV/A

IDS

Fu

nd

ing

Care Research Prevention International Cash and Housing Assistance

Federal HIV/AIDS Funding Federal HIV/AIDS Funding Trends, Programs Over $1 Trends, Programs Over $1

Billion, 2003-2005Billion, 2003-2005

2003 Actual2004 Estimated

2005 Request

$0.00

$1,000.00

$2,000.00

$3,000.00

$4,000.00

$5,000.00

$6,000.00

Millions

Ryan White Care Act National Institutes of Health Medicaid (Federal Share) Medicare SSDI

Federal HIV/AIDS Funding Federal HIV/AIDS Funding Trends, Programs Under 1 Trends, Programs Under 1

Billion, 2003-2005Billion, 2003-2005

$150.00

$200.00

$250.00

$300.00

$350.00

$400.00

$450.00

$500.00

2003 Actual 2004Estimated

2005 Request

Mill

ions HOPWA

SAMHSA

SSI

Veteran's Affairs

Federal EmployeesHealth BenefitsOther

The Minority Initiative as a Proportion The Minority Initiative as a Proportion of Total HIV/AIDS Fundingof Total HIV/AIDS Funding

2%

98%

Minority Initiative Other HIV/ AIDS Funding

The Minority Initiative and The Minority Initiative and Other HIV/AIDS Funding, Other HIV/AIDS Funding,

1999-2004 1999-2004

$0

$2,000

$4,000

$6,000

$8,000

$10,000

$12,000

$14,000

$16,000

$18,000

1999 2000 2001 2002 2003 2004

Mill

ions

Minority Initiative Other HIV/ AIDS Funding

Minority Initiative Minority Initiative Allocations, 1999-2004Allocations, 1999-2004

$0

$50

$100

$150

$200

$250

$300

$350

$400

1999 2000 2001 2002 2003 2004

Mill

ions

Ryan White

CDC

SAMHSA

Office oftheSecretary

NIH

State Funding TrendsState Funding Trends State’s Budget Crisis Arises from State’s Budget Crisis Arises from

Economic DownturnEconomic Downturn Tax Cuts enacted in the 76Tax Cuts enacted in the 76thth session session Cumulative effect of funding defermentsCumulative effect of funding deferments

Texas Medicaid Costs are RisingTexas Medicaid Costs are Rising Continued to Rise When Enrollments were DecliningContinued to Rise When Enrollments were Declining Enrollments have Begun to Increase AgainEnrollments have Begun to Increase Again

7878thth Legislative Session Implemented Cost- Legislative Session Implemented Cost-Control Measures for Medicaid Control Measures for Medicaid Preferred Drug ListPreferred Drug List Managed Care ExpansionManaged Care Expansion Disease ManagementDisease Management Prior Authorization of High Cost Medical ServicesPrior Authorization of High Cost Medical Services

State Funding TrendsState Funding Trends Health and Human Services Commission to Issue Health and Human Services Commission to Issue

Smart Cards with Fingerprint Scans to “Prevent Smart Cards with Fingerprint Scans to “Prevent Medicaid Fraud”Medicaid Fraud”

State Plans to Discontinue Primary Care Case State Plans to Discontinue Primary Care Case Management and Replace it with HMOsManagement and Replace it with HMOs

State Cuts in Medicare and Deep and Far-State Cuts in Medicare and Deep and Far-ReachingReaching Total Health Care Cuts in the 78Total Health Care Cuts in the 78thth Legislative Session Legislative Session

Add Up to Over 1 BillionAdd Up to Over 1 Billion Cuts Include $42.1 Million for Mental Health AloneCuts Include $42.1 Million for Mental Health Alone State Budget Cuts in Medicaid Mean Texas Will Lose State Budget Cuts in Medicaid Mean Texas Will Lose

$1.6 Billion in Federal Medicaid Assistance$1.6 Billion in Federal Medicaid Assistance State Comptroller Advocating $1 Increase in Cigarette State Comptroller Advocating $1 Increase in Cigarette

Tax to Restore CutsTax to Restore Cuts Current Legislative Behavior Make It Unlikely that Texas Current Legislative Behavior Make It Unlikely that Texas

Will Use the ETHA Option If It Becomes AvailableWill Use the ETHA Option If It Becomes Available

State Funding Trends: State Funding Trends: ADAPADAP

Size of Texas ADAP is Already Modest Size of Texas ADAP is Already Modest Compared to Other StatesCompared to Other States

Texas ADAP Serves an Estimated 25% of Texas ADAP Serves an Estimated 25% of Texans Living with HIV/AIDSTexans Living with HIV/AIDS

Texas Imposes a 3-Drug Limit on ADAP UseTexas Imposes a 3-Drug Limit on ADAP Use Fifteen States Have ADAP Waiting Lists or Fifteen States Have ADAP Waiting Lists or

RestrictionsRestrictions Six More Are Contemplating SuchSix More Are Contemplating Such This Year, Texas Participated in Joint State This Year, Texas Participated in Joint State

Negotiations to Obtain Lower Drug Pricing Negotiations to Obtain Lower Drug Pricing for ADAPfor ADAP

Early Treatment for HIV Act Early Treatment for HIV Act (ETHA)(ETHA)

Allows States to Create Medicaid Eligibility Allows States to Create Medicaid Eligibility Category Specifically for HIVCategory Specifically for HIV

Similar to Previous Breast Cancer LegislationSimilar to Previous Breast Cancer Legislation In 1999, Congress expanded Medicaid to give In 1999, Congress expanded Medicaid to give

states the option of extending Medicaid to women states the option of extending Medicaid to women with breast and cervical cancerwith breast and cervical cancer

Women in this option are not required to Women in this option are not required to demonstrate disability or low incomedemonstrate disability or low income

44 states have expanded Medicaid to provide 44 states have expanded Medicaid to provide women access to cancer treatmentwomen access to cancer treatment

Texas became one of those states in February Texas became one of those states in February 20012001

Early Treatment for HIV Act Early Treatment for HIV Act (ETHA)(ETHA)

Would Shift Costs from ADAP to Would Shift Costs from ADAP to MedicaidMedicaid

Would extend coverage to an Would extend coverage to an estimated 18,000 people at a per-estimated 18,000 people at a per-person cost of $5600person cost of $5600

Currently has 20 cosponsors in the Currently has 20 cosponsors in the SenateSenate

Filed in the House on March 3 with Filed in the House on March 3 with 66 cosponsors66 cosponsors

Adult and Child Enrollment Adult and Child Enrollment in Texas Medicaid, 1996-in Texas Medicaid, 1996-

20012001

Jan-96Jan-97

Jan-98Jan-99

Jan-00Jan-01

Sep-01

0

200000

400000

600000

800000

1000000

1200000

1400000

Adult

Children

Texas Medicaid Monthly Texas Medicaid Monthly Average Enrollment, Adult Average Enrollment, Adult

Categories, 1996-2001Categories, 1996-2001

0

50000

100000

150000

200000

250000

300000

350000

Jan-96 Jan-97 Jan-98 Jan-99 Jan-00 Jan-01 Sep-01

Aged and MedicareRelated

Disabled & Blind

TANF Adult

Pregnant Women

Medically Needy

Average Monthly Enrollment Average Monthly Enrollment and Non-Federal Texas and Non-Federal Texas

Medicaid Expenditures, 1996-Medicaid Expenditures, 1996-20032003

0

500000

1000000

1500000

2000000

2500000

3000000

1996 1997 1998 1999 2000 2001 2002 2003 2004

$0

$1,000,000,000

$2,000,000,000

$3,000,000,000

$4,000,000,000

$5,000,000,000

$6,000,000,000

$7,000,000,000

Total Average Monthly Enrollment

Non-Federal Medicaid Spending

Ryan White Funding by Ryan White Funding by Title, US and TexasTitle, US and Texas

Texas Ryan White Funding by Title, 2002

34%

5%

0%

0%

4%

1%

1%

0%

0%

55%

  Title I  Title II (Includes ADAP)  Title III (Early Intervention Services)  Title III (Capacity Grant Program)  Title III (Planning Grant Program)  Title IV  AETC  SPNS  Dental Reimbursement Program  Community Based Dental Partnership Program

US Ryan White Funding by Title, 2002

32%9%

0%

0%

4% 2%1%1%0%

51%

  Title I  Title II (Includes ADAP)  Title III (Early Intervention Services)  Title III (Capacity Grant Program)  Title III (Planning Grant Program)  Title IV  AETC  SPNS  Dental Reimbursement Program  Community Based Dental Partnership Program

Discretionary SAMHSA Discretionary SAMHSA HIV/AIDS Funding, Texas HIV/AIDS Funding, Texas

and Houstonand Houston

$0

$5,000,000

$10,000,000

$15,000,000

$20,000,000

$25,000,000

$30,000,000

$35,000,000

$40,000,000

Texas Discretionary Houston Discretionary

Conclusions and Conclusions and Recommendations: Funding Recommendations: Funding

Distribution Distribution Do Not Rely on HOPWA or SAMHSA Do Not Rely on HOPWA or SAMHSA

Funding to Contribute Substantially Funding to Contribute Substantially Beyond Current Levels Beyond Current Levels FederallyFederally

CDC’s New Prevention Strategy May CDC’s New Prevention Strategy May Increase Availability of Some Limited Increase Availability of Some Limited Social Services for HIV+ PeopleSocial Services for HIV+ People

Funding Should Target Services Toward Funding Should Target Services Toward Minority Men and Women Who Have Sex Minority Men and Women Who Have Sex with Menwith Men

Texas May Implement ETHA, But May Texas May Implement ETHA, But May Not, So Do Not Rely on ItNot, So Do Not Rely on It

Conclusions and Conclusions and Recommendations: Finding Recommendations: Finding

More FundingMore Funding Greater Coordination Between CDC Planning Group, Ryan White Greater Coordination Between CDC Planning Group, Ryan White

Planning Council, and HOPWA/SAMHSA/NIH GranteesPlanning Council, and HOPWA/SAMHSA/NIH Grantees Pooling of needs and resources dataPooling of needs and resources data Sharing of administrative costsSharing of administrative costs More inter-agency, cross-program collaborative projectsMore inter-agency, cross-program collaborative projects Potential to Increase Quality of ServicePotential to Increase Quality of Service

Strength in Numbers (Data and Analysis)Strength in Numbers (Data and Analysis) Strengthens Houston’s Case for HIV/AIDS FundingStrengthens Houston’s Case for HIV/AIDS Funding Strengthens Individual Agency Applications for Discretionary FundsStrengthens Individual Agency Applications for Discretionary Funds Provides Information for Groups Dedicated to Policy ChangeProvides Information for Groups Dedicated to Policy Change

Make Greater Use of Federal Competitive GrantmakingMake Greater Use of Federal Competitive Grantmaking Example: SAMHSA FundsExample: SAMHSA Funds

Texas Receives Over $30,000,000 in Competitive, Discretionary Funds from Texas Receives Over $30,000,000 in Competitive, Discretionary Funds from SAMHSASAMHSA

Of These Funds, Less Than $5,000,000 Went to Houston in 2003-2004Of These Funds, Less Than $5,000,000 Went to Houston in 2003-2004 A Coordinated Effort Could Help Increase the Availability of Mental Health, A Coordinated Effort Could Help Increase the Availability of Mental Health,

Substance Abuse, and Other Non-Medical Services for People with Substance Abuse, and Other Non-Medical Services for People with HIV/AIDS in the Houston EMAHIV/AIDS in the Houston EMA

Similar Coordination Could Increase the Flow of Discretionary Funds from Similar Coordination Could Increase the Flow of Discretionary Funds from Other AgenciesOther Agencies