1. 2004 Environmental Scan: Selected Findings Conducted for the Ryan White Planning Council by RTH Research Group, LLC Roberto Trevino, Ph.D. Alan Jay Richard, Ph.D. Diana Lemos, B.S.

2. Demographic Trends

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

5. Texas exhibited less overall reduction in mortality and greater ethnic disparity after the introduction of HAART than California

6. Medical Trends

7. Ongoing HIV Clinical Trials by Type

8. HIV Vaccine Research Since the first HIV vaccine trial enrolled volunteers in 1988, 49 clinical trials of 26 different vaccine candidates have been studied in clinical trials by NIH Since the first HIV vaccine trial enrolled volunteers in 1988, 49 clinical trials of 26 different vaccine candidates have been studied in clinical trials by NIH At least 13 different gp120 and gp160 envelope candidates have been evaluated in phase I/II trials At least 13 different gp120 and gp160 envelope candidates have been evaluated in phase I/II trials Most research has focused on gp120 rather than gp140/gp160 Most research has focused on gp120 rather than gp140/gp160 NIH spends the most on vaccines, but not enough is being spent in HIV vaccine development NIH spends the most on vaccines, but not enough is being spent in HIV vaccine development

9. Number of Cases and NIAID Research Dollars Spent on Anthrax and HIV/AIDS Vaccines, 2002

10. Vaccine Trials by Vaccine Type

11. Vaccine Trials by Client Population

12. Current Approved Anti-Retrovirals

13. HIV Prevention Trials Network Studies by Targeted Population

14. HIV Prevention Trials Network Studies by Intervention Type

15. Funding Trends

16. Federal Funding Trends Total Federal Funding for HIV/AIDS is a Small Fraction of the Federal Budget Total Federal Funding for HIV/AIDS is a Small Fraction of the Federal Budget Federal funding Continues to Increase but Federal funding Continues to Increase but Increases do not keep pace with the epidemic Increases do not keep pace with the epidemic Increases are concentrated in mandated funding categories Increases are concentrated in mandated funding categories Increases Reflect Changing Policy Priorities Increases Reflect Changing Policy Priorities In recent years, increases do not include minority services, housing services, prevention services, substance abuse services, or mental health services In recent years, increases do not include minority services, housing services, prevention services, substance abuse services, or mental health services

17. Federal Funding Trends (Cont.) Federal funding Continues to Increase but Federal funding Continues to Increase but Funding for Care and Assistance represents a shrinking proportion of all federal funding Funding for Care and Assistance represents a shrinking proportion of all federal funding The Minority Initiative, targeting minority groups disproportionately affected by HIV/AIDS, represents a tiny and shrinking fraction of overall HIV/AIDS funding The Minority Initiative, targeting minority groups disproportionately affected by HIV/AIDS, represents a tiny and shrinking fraction of overall HIV/AIDS funding Minority Initiative SAMHSA funding - the only funding from that agency targeting people living with or at heightened risk for HIV/AIDS - is estimated to drop dramatically in the 2004 budget year Minority Initiative SAMHSA funding - the only funding from that agency targeting people living with or at heightened risk for HIV/AIDS - is estimated to drop dramatically in the 2004 budget year

18. Total Federal HIV/AIDS Funding Increased Steadily, with a More Dramatic Increase Between 2000 and 2001

19. Meanwhile, the Number of Persons Living with HIV/AIDS Also Continues to Increase

20. So Spending Per Person Living with HIV/AIDS has Actually Decreased Slightly since 2001

21. Yearly Changes Among Funding Categories Reveal More Shifts in Priorities

22. Starting in 2001, Total HIV/AIDS Funding Increases Began to Outpace Increases for Care and Assistance

23. Starting this Fiscal Year, the Proportion of HIV/AIDS Funding Designated for International Assistance Increases, while the Proportion Designated for Prevention, Cash/Housing Assistance, and Research Decreases

24. Federal HIV/AIDS Funding Trends, Programs Over $1 Billion, 2003-2005

25. Federal HIV/AIDS Funding Trends, Programs Under 1 Billion, 2003-2005

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

27. The Minority Initiative and Other HIV/AIDS Funding, 1999-2004

28. Minority Initiative Allocations, 1999- 2004

29. State Funding Trends State’s Budget Crisis Arises from State’s Budget Crisis Arises from Economic Downturn Economic Downturn Tax Cuts enacted in the 76 th session Tax Cuts enacted in the 76 th session Cumulative effect of funding deferments Cumulative effect of funding deferments Texas Medicaid Costs are Rising Texas Medicaid Costs are Rising Continued to Rise When Enrollments were Declining Continued to Rise When Enrollments were Declining Enrollments have Begun to Increase Again Enrollments have Begun to Increase Again 78 th Legislative Session Implemented Cost-Control Measures for Medicaid 78 th Legislative Session Implemented Cost-Control Measures for Medicaid Preferred Drug List Preferred Drug List Managed Care Expansion Managed Care Expansion Disease Management Disease Management Prior Authorization of High Cost Medical Services Prior Authorization of High Cost Medical Services

30. State Funding Trends Health and Human Services Commission to Issue Smart Cards with Fingerprint Scans to “Prevent Medicaid Fraud” Health and Human Services Commission to Issue Smart Cards with Fingerprint Scans to “Prevent Medicaid Fraud” State Plans to Discontinue Primary Care Case Management and Replace it with HMOs State Plans to Discontinue Primary Care Case Management and Replace it with HMOs State Cuts in Medicare and Deep and Far-Reaching State Cuts in Medicare and Deep and Far-Reaching Total Health Care Cuts in the 78 th Legislative Session Add Up to Over 1 Billion Total Health Care Cuts in the 78 th Legislative Session Add Up to Over 1 Billion Cuts Include $42.1 Million for Mental Health Alone Cuts Include $42.1 Million for Mental Health Alone State Budget Cuts in Medicaid Mean Texas Will Lose $1.6 Billion in Federal Medicaid Assistance State Budget Cuts in Medicaid Mean Texas Will Lose $1.6 Billion in Federal Medicaid Assistance State Comptroller Advocating $1 Increase in Cigarette Tax to Restore Cuts State Comptroller Advocating $1 Increase in Cigarette Tax to Restore Cuts Current Legislative Behavior Make It Unlikely that Texas Will Use the ETHA Option If It Becomes Available Current Legislative Behavior Make It Unlikely that Texas Will Use the ETHA Option If It Becomes Available

31. State Funding Trends: ADAP Size of Texas ADAP is Already Modest Compared to Other States Size of Texas ADAP is Already Modest Compared to Other States Texas ADAP Serves an Estimated 25% of Texans Living with HIV/AIDS Texas ADAP Serves an Estimated 25% of Texans Living with HIV/AIDS Texas Imposes a 3-Drug Limit on ADAP Use Texas Imposes a 3-Drug Limit on ADAP Use Fifteen States Have ADAP Waiting Lists or Restrictions Fifteen States Have ADAP Waiting Lists or Restrictions Six More Are Contemplating Such Six More Are Contemplating Such This Year, Texas Participated in Joint State Negotiations to Obtain Lower Drug Pricing for ADAP This Year, Texas Participated in Joint State Negotiations to Obtain Lower Drug Pricing for ADAP

32. Early Treatment for HIV Act (ETHA) Allows States to Create Medicaid Eligibility Category Specifically for HIV Allows States to Create Medicaid Eligibility Category Specifically for HIV Similar to Previous Breast Cancer Legislation Similar to Previous Breast Cancer Legislation In 1999, Congress expanded Medicaid to give states the option of extending Medicaid to women with breast and cervical cancer In 1999, Congress expanded Medicaid to give states the option of extending Medicaid to women with breast and cervical cancer Women in this option are not required to demonstrate disability or low income Women in this option are not required to demonstrate disability or low income 44 states have expanded Medicaid to provide women access to cancer treatment 44 states have expanded Medicaid to provide women access to cancer treatment Texas became one of those states in February 2001 Texas became one of those states in February 2001

33. Early Treatment for HIV Act (ETHA) Would Shift Costs from ADAP to Medicaid Would Shift Costs from ADAP to Medicaid Would extend coverage to an estimated 18,000 people at a per-person cost of $5600 Would extend coverage to an estimated 18,000 people at a per-person cost of $5600 Currently has 20 cosponsors in the Senate Currently has 20 cosponsors in the Senate Filed in the House on March 3 with 66 cosponsors Filed in the House on March 3 with 66 cosponsors

34. Adult and Child Enrollment in Texas Medicaid, 1996-2001

35. Texas Medicaid Monthly Average Enrollment, Adult Categories, 1996- 2001

36. Average Monthly Enrollment and Non- Federal Texas Medicaid Expenditures, 1996-2003

37. Ryan White Funding by Title, US and Texas

38. Discretionary SAMHSA HIV/AIDS Funding, Texas and Houston

39. Conclusions and Recommendations: Funding Distribution Do Not Rely on HOPWA or SAMHSA Funding to Contribute Substantially Beyond Current Levels Federally Do Not Rely on HOPWA or SAMHSA Funding to Contribute Substantially Beyond Current Levels Federally CDC’s New Prevention Strategy May Increase Availability of Some Limited Social Services for HIV+ People CDC’s New Prevention Strategy May Increase Availability of Some Limited Social Services for HIV+ People Funding Should Target Services Toward Minority Men and Women Who Have Sex with Men Funding Should Target Services Toward Minority Men and Women Who Have Sex with Men Texas May Implement ETHA, But May Not, So Do Not Rely on It Texas May Implement ETHA, But May Not, So Do Not Rely on It

40. Conclusions and Recommendations: Finding More Funding Greater Coordination Between CDC Planning Group, Ryan White Planning Council, and HOPWA/SAMHSA/NIH Grantees Greater Coordination Between CDC Planning Group, Ryan White Planning Council, and HOPWA/SAMHSA/NIH Grantees Pooling of needs and resources data Pooling of needs and resources data Sharing of administrative costs Sharing of administrative costs More inter-agency, cross-program collaborative projects More inter-agency, cross-program collaborative projects Potential to Increase Quality of Service Potential to Increase Quality of Service Strength in Numbers (Data and Analysis) Strength in Numbers (Data and Analysis) Strengthens Houston’s Case for HIV/AIDS Funding Strengthens Houston’s Case for HIV/AIDS Funding Strengthens Individual Agency Applications for Discretionary Funds Strengthens Individual Agency Applications for Discretionary Funds Provides Information for Groups Dedicated to Policy Change Provides Information for Groups Dedicated to Policy Change Make Greater Use of Federal Competitive Grantmaking Make Greater Use of Federal Competitive Grantmaking Example: SAMHSA Funds Example: SAMHSA Funds Texas Receives Over $30,000,000 in Competitive, Discretionary Funds from SAMHSA Texas Receives Over $30,000,000 in Competitive, Discretionary Funds from SAMHSA Of These Funds, Less Than $5,000,000 Went to Houston in 2003-2004 Of These Funds, Less Than $5,000,000 Went to Houston in 2003-2004 A Coordinated Effort Could Help Increase the Availability of Mental Health, Substance Abuse, and Other Non-Medical Services for People with HIV/AIDS in the Houston EMA A Coordinated Effort Could Help Increase the Availability of Mental Health, Substance Abuse, and Other Non-Medical Services for People with HIV/AIDS in the Houston EMA Similar Coordination Could Increase the Flow of Discretionary Funds from Other Agencies Similar Coordination Could Increase the Flow of Discretionary Funds from Other Agencies