Evaluation of Availability of Sexual Health and Substance Use Services in Texas 2021

Report

Carla N. Noreen

Department of Public Health, Baylor University

Summer Public Health Practicum

Dr. Emeka Okafor, PhD, MPH

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

15% increase of people with HIV (PWH) with approximately 97,844 Texans having HIV (Texas

Department of State Health Services, 2021). According to data from the Centers of Disease

Control and Prevention, only about 83.3% of PWH in Texas were aware of their status and about

74.6% of PWH had been linked to care and services. 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 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 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). The breakdown of 2018 statistics

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 (Texas DSHS

HIV/STD Program - Disease Reporting, 2020). This is consistent with 2018 reports of PWH by

sex showing that 78.8% of PWH were male while 21.2% were female. Considering 36% of PWH

were Hispanic males and 24% were Hispanic females, the need for increased interventions

among this demographic is also apparent. Low-income, sexual minority, and immigrant Hispanic

communities are at the greatest risk of HIV in Texas due to multiple marginalization, or the

social oppression that occurs when a person has more than one minority identifier (Tabler et al.,

2019). Many programs have aimed to be proactive amongst this community in raising STD

awareness and safe sex practices as sexual minority Hispanics report being less knowledgeable

due to perceived stigma, health care discrimination, low health care utilization, and ethnic

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homophobia (Tabler et al., 2019). Research mapping STD/HIV testing in Texas showed areas

where low-income areas of minority populations had a low percentage of preventive testing and

high rate of testing once emergent symptoms were reported (Oppong et al., 2012). Treatment for

HIV heavily relies early identification of infection and treatment initiation to prevent the

escalation of the infection and symptoms. To promote a well-adjusted life after an HIV

diagnosis, early testing is key for Texas communities. Although many initiatives have worked all

over the state to alleviate the burden of HIV, 2018 statistics showed that 19.5% of new HIV

diagnoses were diagnosed late (AIDSVu, 2019). A late diagnosis is considered to be an AIDS

diagnosis 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 (Texas DSHS HIV/STD Program - Disease Reporting, 2020). 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. Included in the vulnerable populations are the population of opiate users. Injection

drug users are at a high risk of contracting and transmitting HIV as syringes and needles may be

contaminated (HIV and Substance Use CDC, 2021). In 2018, 6.4% of males and 17.9% of

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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’ sexual health is being properly cared for. The size of the state, lack

of receipt of services and decreased health access poses a great risk to Texas populations (Tabler

et al., 2019). In many cases, the ease of availability promotes frequent 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 also aims to fill in the gap found in literature as there is a lack

of understanding how the presence of STD, HIV, PrEP, and opioid services in Texas counties

effects HIV incidence and prevalence.

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

health-seeking behaviors, education efforts, and resource availability. Because of this, our 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 considering factors such as

population size and socioeconomic status.

Methods

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 sexually transmitted diseases, 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.

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STD Testing and Services

The Youth AIDS Coalition is a United States based website that offers STD testing sites

and information (2021). The YAC works to raise awareness on sexual health and wellness while

providing accessible education. Visitors can use the YAC 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.

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 services for PWH, recommendations for

local programs were listed. 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

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

recommendations. If they did not have any recommendations, neighboring counties that had

PrEP programs were listed instead as the PrEP referral.

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 United States (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 United States Department of Health and Human Services has organized the

Substance Abuse and Mental Health Services Administration, or 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 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

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Bureau, the American Community Survey Demographics and Housing Estimates of 2019 was

used as part of our research.

Phone Interviews

Phone calls were placed to clinics for information on services and 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.

Variables Analyzed

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

testing and/or education. The availability of treatment services was not deemed 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

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

Buprenorphine and Suboxone clinics.

For each county, 23 different variables were thoroughly investigated from a multitude of

resources. The variables analyzed are described in the table on the following page as well as any

specific years that were used to collect data. For services and mileage, no specific year was used

for collection. 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.

Table 1
Variables Analyzed with Corresponding Year of Data and Source
Variable Year Data Source
Prevalence of HIV 2019 DSHS
Incidence of HIV 2019 DSHS
DSHS Region 2021 DSHS
Health Dept Website 2021 Google
Population Size 2019 U.S. Census Bureau
Racial Demographics 2019 U.S. Census Bureau
Median Income 2019 U.S. Census Bureau
STD Service 2021 YAC, Google, Recommendations
STD Service Within County? 2021 Google Maps
Distance between STD and HIV Service 2021 Google Maps
HIV Service 2021 DSHS, Google, Recommendations
HIV Service Starting Year ------ Phone Interview, Google
HIV Service Within County? 2021 Google Maps
Distance between HIV and PrEP Service 2021 Google Maps
PrEP Service 2021 DSHS, Google, Recommendations
PrEP Service Starting Year ------ Phone Interview, Google
PrEP Service Within County? 2021 Google Maps
Distance between PrEP and Opioid Service 2021 Google Maps
Opioid Service 2021 SAMHSA
Opioid Service Starting Year ------ Phone Interview, Google
Opioid Service Within County? 2021 Google Maps
Distance between STD Service and County 2021 Google Maps
Opioid Related Deaths 2019 DSHS
Opioid Related Deaths 2020 DSHS
Needle Exchange Program 2021 NASEN, SAMHSA

Data Collection

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 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. Data collection began by

evaluating all counties with a rate equal to or above 8.0 per 100,000 people. This led to a sample

of 67 counties. Case and rate information from the report were used as incidence and prevalence

data, respectively. After collecting case and rate data on the 67 counties, the DSHS regional map

was used to detail which region each county belonged to.

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

Survey Demographics and Housing Estimates of 2019 provided by and operated under the U.S.

Census Bureau. Filters were applied to the data set to only produce information associated with

the counties being evaluated in our sample. Variables collected from the U.S. Census Bureau

included 2019 population size, median income, and racial demographics.

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

health district. All health departments were listed and 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

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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.

An official data request was sent to DSHS Center for Health Statistics for counts of

opioid related deaths in Texas from 2019-2020. Some counties did not have counts available and

were left blank in documentation. For security reasons and anonymity concerns, counties with

deaths between 1-9 were denoted with an asterisk to protect confidential data.

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.

Because we were collecting data in the year 2021 and using opioid-related death counts

from 2019, we also included the years in which each service began (specifically PrEP and

opioid). This is important as it gives context to the potential relationship between the presence of

services and its effects on opioid-related deaths. Not all services had this information or were

open to answer questions as the COVID-19 pandemic has halted the operations of some services

(see Limitations below).

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/binary variable.

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

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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 median income as a socioeconomic status indicator. Previous literature showed that

populations with a higher income had greater access to sexual education and prevention efforts.

Both variables were included in model building to prevent bias. Next, models were created to

determine the association between the presence of STD, HIV, PrEP, and opioid services in

county and HIV incidence level data. 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. An additional model was

created examining the association between presence of opioid services in county and opioid

deaths in 2019. Listwise deletion was used to overcome the issues of missing data. Finally,

confidence intervals were obtained for all model estimates. All statistical analyses used RStudio

1.4.

Results

The sample included 67 counties, with the presence of services (in or out of county)

shown in Table 2. Among the four services evaluated, STD services had the largest presence in

counties. In our sample, 55.2% of counties had STD services in county (n=67). Opioid services

were the second-most present service in county with 40.3% of the sample. HIV services ranked

third in our sample with 35.5% in county. PrEP services were the least present in our sample

with only 25.4% being in county. Other than STD services, opioid, HIV, and PrEP services were

most found outside of the county than in county. The mean incidence of HIV for the sample was

55.16, with the minimum being 1.00 and maximum being 1,172.00 per 100,000 people. The

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mean prevalence of HIV in our sample was 14.90 with the minimum being 8.00 and maximum

being 62.50 per 100,000 people. Harris county had the highest incidence of HIV among the

sample with 1,172 per 100,000 people. Crane county had the highest prevalence of HIV with

62.5 per 100,000 people. As for starting years for PrEP services, the oldest program was from

1965 and the most recent program started in 2020. On average, PrEP services evaluated in our

sample began around 1998. For opioid services, most programs began around 1989 with the

oldest service beginning in 1953 and the youngest starting in 2021.

The data collected compared the 4 predictor variables to our outcome, HIV incidence.

Table 2 shows the breakdown for the counties in our sample and how many different

clinics/programs were used to offer all four of our observed services. As seen in the table below,

only 1 county used one single location for all four services. All other counties used at least 2

locations to fulfill all the STD, HIV, PrEP, and opioid needs of the population.

Table 2
Number of Different Locations used by Counties
Counties Number of Locations Used
1 1
33 2
25 3
8 4
N=67, 4 services examined (STD, HIV, PrEP, Opioid)

It is also important to note how many locations were used by multiple counties. During data

collection, it seemed that certain regions of Texas relied heavily on specific programs for sexual

health services. The repeated use of these services by Texas residents shows how much of the

population must travel outside of their county to receive services. Table 3 below demonstrates

the number of different locations used for each variable reviewed.

Table 3

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 Number of Different Locations used for each Service
STD HIV PrEP Opioid
59 50 41 54
N=67

Our data showed an interesting relationship between the availability of sexual health

resources and HIV incidence. Table 4 demonstrates the estimated coefficients, confidence

intervals, and p-values from the adjusted models. When looking at the availability of services

against HIV incidence in our sample, HIV services showed to be statistically significant

(p=0.02). The Beta estimate for services in county showed that HIV services had a negative

effect on HIV incidence (adjusting for population and income). There was no significant

difference in the other services (STD, PrEP, and opioid) but all had a negative relationship as

well. Even though the results did not have a significant p-value (p<0.05), the direction of the

estimate coefficient was negative, as predicted in our hypothesis. For example, the association

between PrEP services being in county compared to PrEP services out of county showed a lower

estimate of -1.527e+01 (p=0.23).

Table 4
Association between Presence of Services Within County and HIV Incidence Rate*
Service N Beta (95% C.I.) P-Value
STD
Yes 37 -1.372e+01 (-34.45, 7.05) 0.191595
No 30 reference reference
HIV
Yes 24 -2.560e+01 (-4.77, -3.50) 0.023897*
No 43 reference reference
PrEP
Yes 17 -1.527e+01 (-4.02, 9.63) 0.224989
No 50 reference reference
Opioid
Yes 27 -1.017e+01 (-3.36, 13.24) 0.38870
No 40 reference reference
*
Adjusted for income and population level.

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 Using opioid-related deaths counts in 2019, we also evaluated how opioid services

affected these counties. Not all 67 counties were included in opioid-related death data, and

therefore we only had 40 data points to observe. When analyzing this data, the direction of the

coefficients described a negative relationship between the presence of opioid services and

opioid-related deaths (p=0.4805). The associated regression estimate (-4.4710) was within the

95% confidence interval (-16.8908, 7.9488). Although insignificant, this did correspond with our

hypothesis.

Discussion

Our results showed that availability of STD, HIV, PrEP, and opioid services were

associated with reduced HIV incidence. In addition, availability of opioid treatment services was

associated with reduced opioid overdose deaths.

Research has shown that the use of PrEP is crucial in reducing the risk of HIV at the

individual level (Oppong et al., 2012). Despite this, PrEP services have been shown to be

difficult to obtain in Texas counties, especially considering the lack of insurance coverage

among vulnerable populations (Tabler et al., 2019). As of July 2021, new legislation stemming

from a collaborative effort between the Centers for Medicare and Medicaid Services, Department

of Labor, and the Department of Treasury, ruled that health insurers must begin to cover all PrEP

prescriptions including quarterly clinic appointments and labs required to stay on the drug (Ryan,

2021). This new requirement will hopefully increase access to PrEP services for those at risk and

will eliminate the financial barrier many individuals face when trying to obtain the prescription.

This new legislation couple with our study has showed that the demonstrating a negative

association between PrEP services and HIV incidence leads us to believe that the widespread

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availability of PrEP services can make a difference at the individual level and eventually

population level.

During data collection, it was evident that STD services were the most common sexual

health resource available to Texas residents. This is seen in Table 2 as STD services had a

greater presence in county compared to the other four variables. The high amount of STD

services in county were consistent with previous literature as STD resources such as education,

prevention, testing, and treatment are the most common sexual wellness services. Although this

is important and helpful, it also shows that simple STD testing can no longer be the standard for

sexual health and wellness. Previous literature showed that while regular HIV testing is critical

for detecting HIV early, people who test only after symptoms present themselves contribute to

the number of people living with undiagnosed HIV which subsequently creates a larger public

health issue of access to quality health care and prevention efforts (Oppong et al., 2012).

Our finding suggests that increasing the availability of services may help increase

awareness of HIV services and facilitate early entry in HIV treatment as Texas residents will not

have to overcome barriers associated with having to travel outside of their county for care. If

services were available in more counties, residents may be more likely to use the resources

frequently and help decrease the risk and/or incidence of HIV. Our results showed that many

services were used for multiple counties showing that many residents all over the state must

travel outside of their county to receive care. Having this data is helpful because it shows how

many programs/clinics are used in multiple counties leading to more of the county’s residents

having to travel for care. With a larger percentage of the population using resources because of

the ease of availability and service, the overall burden of HIV prevalence may be decreased. Our

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results show that an increased sample size may help with showing negative associations with

significant p-values and further demonstrate the need for public health intervention.

Limitations

A major limitation for this report was the sample size used to begin the evaluation.

Further research should focus on expanding the results to include all counties within Texas. This

report used population-level aggregate data. If this research were to continue, adding individual

level data may significantly improve the findings and increase the information gained from

analysis. Due to COVID-19, some health departments and services in Texas were suspended.

This impacted our research as some counties had previously existing sexual health and wellness

resources for their residents that were unfortunately impacted by the global pandemic. Special

consideration must be given to this circumstance if research were to move forward. Many PrEP

and opioid services were contacted to obtain information on when their services started. Some

services contacted did not have that information. This information would have been helpful as

data on HIV incidence and opioid-related deaths are from 2019 and services being examined are

from 2021. Additionally, more in-depth research can be done on opioid related deaths. The data

acquired from a DSHS data request did not provide death counts for each county being

evaluated. This led to the use of listwise deletion of data to avoid having to eliminate incomplete

data. Specific ICD-10 codes may be used to further specify opioid-related cause of deaths.

Finally, further developments are needed for appropriate estimations of the proportion of

injection drug users and people with substance use issues in the state of Texas as the lack of

information was evident and a hinderance to our research.

Recommendations

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 Having individual level data may improve distance travelled data as researchers can

investigate the mileage and driving time necessary for individuals to utilize services. Mileage

and travel times were collected but due to the aggregate nature of the data, no analysis was

performed. Further research using individual level data can include calculating the distance

between each service and individuals’ homes, rather than from the county itself to each service

as we did. The availability of this information can lead to a visual representation of the state of

Texas, services available, and driving times to each service. This map can show areas within the

state that are left vulnerable as they lack services and are further from resources. A visual

representation as such can be extremely helpful to demonstrate the need for increasing

availability of resources to reduce the sexual health risks isolated populations may suffer from.

Additionally, the evaluation of PrEP services past 2021 would be significant with the

changing legislation for insurance carriers as recommended by the United States Preventive

Services Taskforce (2021). Trends of PrEP usage and availability due to the new ruling can help

further display the relationship between the prescription and HIV incidence.

Also, a valuable component would be comparing existing services to national standards

upheld by health institutions such as the CDC or WHO. Ensuring that the services available are

up to date and meet requirements will also determine whether the residents of Texas are being

delivered quality health care. Future research should also consider minority populations such as

Hispanic/Latinos, Black/African Americans, Asian/Asian Americans, and/or LGBT+ in their

evaluation of services. It should not be missed that programs and interventions carry a

responsibility to offer tailored services to these groups and others as research has shown that

minority populations face a greater risk of marginalization and vulnerability (Tabler et al., 2019).

Conclusion

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 Our study began with examining whether the presence of STD, HIV, PrEP, and opioid

services in Texas counties reduced HIV incidence. Our results spoke to the need to expand

services across Texas as areas without assistance are left vulnerable to disease and a decreased

quality of life. As more Texas residents find themselves in areas without sexual health services,

the concern for HIV incidence in the total population increases. Having to travel outside of the

county and potentially great distances poses a critical issue of public health. The reality of these

vulnerable areas is that every extra mile, phone call, and clinic is another reason for people to not

seek services until they are in emergent need. A streamlined process for services is needed to

help the most people in a convenient, efficient, and productive manner. Increasing the number of

in-county services is critical to combating HIV incidence, reducing risk among vulnerable

populations, and increasing the quality of life of residents across Texas.

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 REFERENCES

Texas Department of Health and Human Services.

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