# Presentation: 036443

## HIV/AIDS and Substance Abuse: Connecting the Dots 

**Jane C. Maxwell, Ph.D.**
**Center for Excellence in Drug Epidemiology**
**Gulf Coast Addiction Technology Transfer Center**
**www.gcattc.net**

## Data Sources

**Overdose death certificates & Medical Examiner Reports (Texas Dept. of State Health Services)**
**Poison Control Center cases (DSHS)**
**Treatment admission records (TEDS-SAMHSA, DSHS)**
**Price, purity, supply, trafficking data (DEA, NFLIS)**
**Surveys (NSDUH-SAMHSA, MTF,YRBS, DSHS)**
**Community Epidemiology Work Group (NIDA) **
**Forensic laboratory tests (NFLIS, Police & ME Labs)**
**AIDS cases (Health Department, DSHS)**

## DEATH BY POWERPOINT
I hope not!
1. Online data sources you can easily access when writing proposals.
2. Changes in the drug and alcohol scene over time and what may be coming in terms of HIV/AIDS risks. 
3. Different ways to display the data to help people understand the problem.

***I hope not!***
- 1. Online data sources you can easily access when writing proposals.
- 2. Changes in the drug and alcohol scene over time and what may be coming in terms of HIV/AIDS risks.
- 3. Different ways to display the data to help people understand the problem.

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**  **

**Community Epidemiology Workgroup Correspondents**

- Austin

- Atlanta

- Miami

- St. Louis

- Chicago

- Detroit

- Minneapolis

- Boston

- New York

- Newark

- Philadelphia

- D.C/Baltimore.

- Phoenix

- Denver

- Seattle

- Los Angeles

- San Diego

- San Francisco

- Honolulu

- CVG

- New Mexico

- Maine

- Map by JC Maxwell

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## Drug Use Patterns Vary over Time and Space

## Percentage of Drug Items Analyzed by Tox Labs Identified by Region, NFLIS 2007

- Source: NFLIS

## Percentage of Drug Items Identified by Toxicological Labs as Heroin by State, 2006

## Percentage of Drug Items Analyzed by Tox Labs Identified as Cocaine, by State, 2006

## Percentage of Drug Items Analyzed by Tox Labs Identified as Methamphetamine, by State, 2006

##  Past Year Injection Drug Use among Persons Aged 12 or Older, by Region: Percentages, NSDUH 2002-2005 

- Source: SAMHSA

## 2008 CEWG Reports: South

**Georgia: Females comprise 24% of AIDS cases, 76% of new ADIS cases are Black.**
**Florida: 40% MSM, 17% IDU, 4% MSM/IDU**
**Texas: Majority of cases are non-White; in 2007, 54% MSM, 26% heterosexual, 14% IDU, 6% MSM/IDU.**
**Baltimore: 57% of AIDS cases in 2006 were IDU.**

## 2008 CEWG Reports: West

**Seattle: 2005-2007 cases: 62% MSM, 8% MSM/IDU, 7% heterosexual, 6% IDU.**
**Colorado: 2007 cases: 61% MSM, 27% Other, 7% IDU, 5% MSM/IDU. IDU decreasing.**
**San Francisco: Heterosexual and MSM increased by 1.9% in past year, with MSM/IDU increasing 2.3%, transgender by 4.4%.**
**Los Angeles: 2007: 65% MSM.**
**Phoenix: IDU cases slowly declining.**

## 2008 CEWG Reports: Midwest

**Detroit: IDUs account for 20%, 90% Black.**
**Chicago: IDU by young Blacks is rare; new IDUs are suburban Whites. Prevalence of HIV among IDU has declined markedly.**
**St Louis: 2007: 79% MSM, 16% heterosexual, 4% IDU.**
**Minnesota: 2007: 51% MSM, 16% heterosexual, 7% IDU, 5% MSM/IDU.**

## 2008 CEWG Reports: East

**Philadelphia: 2006: 49% heterosexual, 26% MSM, 23% IDU, 2% MSM/IDU.**
**New York City: PLWHA 2006: 30% MSM, 21% IDU, 17% heterosexual.**
**Boston: 2006: 57% MSM, 5% IDU, 29% Unknown.**
**Maine: 2006: 57% MSM, 14% IDU, 11% heterosexual, 3% MSM/IDU.**

## U.S. Treatment Admissions by Primary Substance of Abuse: 1992-2006

- Source: SAMHSA

## And Our Demand for Drugs Influences Drug Use in Our Neighbors

## Primary Drug of Abuse in Mexican Border Programs: 2007

- Source: SISVEA. Non Governmental Treatment Centers. DGE. SSA. 2007

**Crystal**
**42.0%**

**Heroin**
**31.0****%**

**Heroin**
**31.3%**

**Cocaine**
**64.0****%**

**Crystal**
**35.1%**

**Cocaine**
**47.4%**

**Cocaine**
**31.8%**

**Cocaine**
**22.0%**

**Heroin**
**33.0%**

**Heroin**
**15.1%**

## Most Common Seized Drugs: Canada

|  | 1989-1992 |  | 1993- 1997 | 1998- 2002 | 2003- 2007 |
| --- | --- | --- | --- | --- | --- |
| Marijuana |  | 25.2% | 37.8% | 51.3% | 41.5% |
| Cocaine |  | 25.6% | 22.5% | 19.3% | 22.9% |
| Crack cocaine |  | 4.4% | 4.9% | 4.5% | 5.2% |
| Heroin |  | 2.2% | 2.8% | 1.9% | 1.2% |
| Methamphetamine |  | 0.1% | 0.3% | 1.5% | 5.0% |
| MDMA |  | 0.01% | 0.1% | 1.2% | 3.4% |
| PCP |  | 0.9% | 1.4% | 0.8% | 0.3% |
| Others |  | 40.8% | 29.0% | 18.5% | 19.8% |
| N =  |  | 311 025 | 411 427 | 455 151 | 577 033 |

- Source: Office of Research and Surveillance, Health Canada

## British 

- British
- Columbia

- Prairie Provinces

- Ontario

- Quebec

- Atlantic Canada

## Canadian Methamphetamine Seizures: 1988-2007

- Source: Office of Research and Surveillance, Health Canada

## 1998 Miami DMP Samples
Southwest Asian	2.1 % Pure
          Southeast Asian           2.3 % Pure
         South American         19.2 %  Pure

**Southwest Asian****	****2.1 % Pure**
**          ****Southeast Asian           2.3 % Pure**
**         ****South American         19.2 %  Pure**

**Heroin**

## Heroin Sources and Supply Routes

- SWA

- SEA

- Mexican

- So. Amer

**Heroin Sources and Supply Routes**

## Heroin as Percentage of Treatment Admissions & Toxicology Lab Exhibits: US 2000-2007

- Source: SAMHSA, NFLIS

## Sources of Heroin Seized in US Based on Net Weight:1989-2006

- DEA Heroin Signature Program

## Average Purity of Heroin Samples in the US: 1992-2006

- DEA Heroin Signature Program

## Heroin 101

**Black tar heroin in Texas, few mentions of stronger “white” heroin seen east of the Mississippi.**
**Tar normally is injected but increases in snorting powder. Tar is cut with Benedryl, Dormin, Tylenol or Nytol PM, coffee creamer, etc****. ****to become**** ****“Brown Heroin” powder.**
**Increase in young inhalers statewide. “If you snort it, it’s not addictive” rumor.**
**Treatment for young heroin users?**

## Mexican Black Tar Heroin

**Mexican Black Tar Heroin**

**Mexican Brown Heroin**

**South American Heroin**

## Percent of Heroin Inhalers at Admission to Texas Treatment Who are Hispanic: 1989-June 2008

- DSHS data; analysis by JC Maxwell

**69%**

## Age of Heroin Inhalers at Admission to Texas Treatment: 1989-June 2008

**34**

**27**

- DSHS data; analysis by JC Maxwell

## Route of Heroin Administration for Texas Treatment Admissions: 1989-June 2008

- DSHS data; analysis by JC Maxwell

## Heroin Admissions in Texas 2005-6/2008 by Age Group

- Source: DSHS. Analysis by JC Maxwell

## US Heroin Admissions, by Route of Administration: TEDS 1992-2006 

- Source: SAMHSA

## Primary US Heroin Admissions, by Age Group and Route of Administration: TEDS 1995 and 2005 

- Inhale

- Inject

- Source: SAMHSA

## Primary US Heroin Admissions, by Race/Ethnicity and Route of Administration: TEDS 1995 and 2005 

- Inhale

- Inject

- Source: SAMHSA

## Other Opiates

- OxyContin, Vicodin, Darvocet, hydrocodone, oxycodone, methadone, codeine, etc.

## OTHER OPIATES

**Abuse of different opiates varies by region****.**
**Fentanyl abuse is patches in the West, not the rogue powder seen in the Northeast (where heroin is also a white powder).**
**Problem with deaths involving methadone pain pills (as compared to diskettes and syrup used in narcotic treatment programs). **
**Codeine cough syrup and rap music. **
**Kids and pills; adults and pills.**

## Other Opiate Treatment Admissions per 100,000 by State, TEDS: 1995

- Range <1-32

- 6-9

- <6

- Incomplete data

- 13-25

**Other Opiate Treatment Admissions per 100,000 by State, TEDS: 1995**

- 10-12

- 26+

- Source: SAMHSA

## Other Opiate Treatment Admissions per 100,000 by State, TEDS: 2000

- Range<1-72

- 6-9

- <6

- Incomplete data

- 13-25

**Other Opiate Treatment Admissions per 100,000 by State, TEDS: 2000**

- 10-12

- 26+

- Source: SAMHSA

## Other Opiate Treatment Admissions per 100,000 by State, TEDS: 2006

- 26+

- < 6

- 6-9

- 13-25

**Other Opiate Treatment Admissions per 100,000 by State, TEDS: 2006**

- 10-12

- Source: SAMHSA

- Range 2-151

## Nonmedical Use of Pain Relievers in the Past Year among Persons Aged 12 or Older, by Substate Region: Percentages, Annual Averages Based on 2004, 2005, and 2006 NSDUH 

**Source: SAMHSA, 2004, 2005, 2006 NSDUH**

## Source Where Pain Relievers Were Obtained for Most Recent Nonmedical Use among Past Year Users Aged 12 or Older: NSDUH 2006

- 1 The Other category includes the sources: “Wrote Fake Prescription,” “Stole from Doctor’s Office/Clinic/Hospital/Pharmacy,” and “Some Other Way.”

- Bought/Took  from Friend/Relative15%

- Drug Dealer/Stranger4%

- Bought on Internet0.1%

- Other 15%

- Free from Friend/Relative7%

- Bought/Took fromFriend/Relative5%

- OneDoctor
- 81%

- Drug Dealer/Stranger2%

- Other 12%

**Source Where Respondent Obtained**

**Source Where Friend/Relative Obtained**

- One Doctor
- 19%

- More than One Doctor
- 2%

- Free from Friend/Relative56%

- More than One Doctor3%

## Human Exposure Calls to Texas Poison Control Centers about Methadone by Formulation: 1998-2007

- DSHS data; analysis by JC Maxwell

## Reason for Using Prescription Pain Relievers: PATS Attitude Tracking Study: 2005 

**Easy to get from parents' medicine cabinets--62%**
**Available everywhere--52%**
**They are not illegal drugs--51%**
**Easy to get through other people's prescriptions--50%**
**Teens can claim to have a prescription if caught--49%**
**They are cheap--43%**
**Safer to use than illegal drugs--35%**
**Less shame attached to using--33%**
**Easy to purchase over the Internet--32%**
**Fewer side effects than street drugs--32%**
**Can be used as study aids--25%**
**Parents don't care as much if you get caught--21%**

## Non-Medical Past Year Use of Prescription Drugs by Persons Age 12 and Over: NSDUH 2005-2006

*P=*.0S

- Source: NSDUH, 2006

## Cocaine

## Cocaine

**Different routes of administration—Crack vs. powder.**** **
**Injecting cocaine and heroin either together or sequentially (“Speedball”)**
**Risky sexual behaviors while smoking crack and trading drugs for sex in crack houses. Impact on HIV/AIDS rates.**
**Methamphetamine outselling cocaine and crack in some areas; some coke dealers now also selling methamphetamine to compete.**
**Still around with new users. Proportion of crack treatment admissions who are Anglo or Hispanic continues to increase.**

## Cocaine Purity and Percentage of Treatment Admissions & Toxicology Lab Exhibits: US 2000-2007

- Source: SAMHSA. NFLIS

## Race-Ethnicity of US Cocaine Admissions: 1992 v. 2006

- Source: SAMHSA

## Routes of Administration of Cocaine Admissions: TEDS 1995-2006

- Source: SAMHSA

## Slide 67

|  |  |  |  |
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## Route of Administration of Cocaine Admissions to Treatment in US-Mexico Border Programs

- Maxwell et al., 2006.

## Marijuana

**Marijuana**

**Reefer Sadness**

## MARIJUANA

**Fairly stable.**
**Influence of Blunts and Wraps**
**Use with Fry, PCP, DANK, crack, cough syrup, honey, etc., continues****.**
**Continuing references to pot and PCP and embalming fluid (formaldehyde).**** **
**CJ v. Non-CJ treatment admissions**

**Primos--marijuana joint and crack.**
**Fry, Amp--joint and embalming fluid (PCP?)**
**Fry Sticks & Fry Squares--$10 each.**
**Fry Sweets--blunts in embalming fluid.**
**Sweet Houses--sell ready-mades.**
**Candy Blunts--cigarillos in codeine cough syrup.**
**Sherms--menthol cigarettes in embalming fluid.**

## % Texas Secondary Students Who Had Used Any Illicit Drug in the Past Month, by Ethnicity: 1988-2006

- Source: DSHS

## Addiction Severity Index Problems of Texans Treated with Primary Marijuana Problem: 2005

- Source: DSHS

## Alcohol

## % Past Month Alcohol Users in the U.S. Ages 12 to 20: 2005-2006 

- SAMHSA, The NSDUH Report: Quantity and Frequency of Alcohol Use Among Underage Drinkers, 4/2008

## Average # Drinks per Day on the Days Used Alcohol among Past Month U.S. Alcohol Users Ages 12 to 20: 2005-2006 

- SAMHSA, The NSDUH Report: Quantity and Frequency of Alcohol Use Among Underage Drinkers, 4/2008

## Average # Days of Alcohol Use among Past Month U.S. Alcohol Users Ages 12 to 20: 2005-2006 

- SAMHSA, The NSDUH Report: Quantity and Frequency of Alcohol Use Among Underage Drinkers, 4/2008

## Slide 78

## % Having Past Year STD among Young Adults Aged 18 to 25, by Level of Past Month Alcohol Use and Gender: NSDUH 2005 

- Source: SAMHSA

## % Past Year STD among Young Adults Aged 18 to 25, by Past Month Alcohol and Illicit Drug Use and Gender: NSDUH 2005 

- Source: SAMHSA

## Methamphetamine

- They used to say
***Speed Kills?***

- It still does

- They used to say
***Speed Kills?***

## Methamphetamine Forms: Australia

**Methamphetamine Powder**
**IDU Description: Beige/yellowy/off-white powder**

**Base / Paste Methamphetamine**
**IDU Description: ‘Oily’, ‘gunky’, ‘gluggy’ gel, moist, waxy **

**Crystalline Methamphetamine**
**IDU Description: White/clear crystals/rocks; ‘crushed glass’ / ‘rock salt’**

## Yaba, Ya Ba, Ya Ma

**Pressed meth-amphetamine pills. Common in Cambodia,  Lao PDR, Myanmar, Thailand, & Viet Nam.**
**Some mentions in the US. Similar appearance to Ecstasy pills, which also can contain meth.**

## Methamphetamine

**Ice is defined by DEA at 80% pure; MSM (methylsulfonylmethane) is used to cut Ice.**
**Since 2004, laws limiting availability of pseudoephedrine have caused purity of powder and Ice to decrease and price to increase.**
**Border seizures and Mexican laws have limited availability of pseudoephedrine in Mexico and amount of Ice imported into the US to replace “home-cooked” powder.**
**Purity of gram of methamphetamine increased from 49% in 2002 to 69% in 2005 and then decreased to 51% in 2006. **

## Primary Amphetamine/MethamphetamineTEDS Admission Rates: 1992(per 100,000 aged 12 and over)

**35 -  58**

**< 12**

**12 -  35**

**No data**

**Primary Amphetamine/Methamphetamine****TEDS Admission Rates: 1992**(per 100,000 aged 12 and over)

- Source: SAMHSA

## Primary Amphetamine/MethamphetamineTEDS Admission Rates: 1997(per 100,000 aged 12 and over)

**35 -  58**

**< 12**

**12 -  35**

**No data**

- Primary Amphetamine/MethamphetamineTEDS Admission Rates: 1997(per 100,000 aged 12 and over)

- Source: SAMHSA

## Primary Amphetamine/MethamphetamineTEDS Admission Rates: 2006(per 100,000 aged 12 and over)

**35 -  58**

**< 12**

**12 -  35**

**No data**

**Primary Amphetamine/Methamphetamine****TEDS Admission Rates: 2006**(per 100,000 aged 12 and over)

- Source: SAMHSA

## Routes of Administration of Methamphetamine of Clients in US Programs: 1993-2006

- Source: SAMHSA

## Texas Methamphetamine Treatment

|  |   Smoke |   Inject |   Inhale |   Oral |
| --- | --- | --- | --- | --- |
| # Admissions | 5,046    | 2,909    | 849    | 430    |
| % of Stimulant Admits | 53 | 30 | 9 | 5 |
| Lag-1st Use to Tmt-Yrs. | 10    | 14    | 10    | 12    |
| Average Age-Yrs. | 31    | 33    | 32    | 34    |
| % Male | 42    | 46    | 47    | 44    |
| % African American | 2    | 1    | 2    | 7    |
| % White | 81    | 92    | 81    | 77    |
| % Hispanic | 16    | 5    | 16    | 14    |
| % CJ Involved | 63    | 65    | 63    | 63    |
| % Employed | 31    | 22    | 31    | 32    |
| % Homeless | 8    | 11    | 8    | 5    |

**Texas Methamphetamine Treatment**
**Admissions: 2007 (TEDS)**

- Source: DSHS, Analysis by J C Maxwell

## ASI Scores of Texas Methamphetamine TreatmentAdmissions: 2007

- Analysis by J C Maxwell

## # Methamphetamine Clandestine Laboratory  Incidents and % of All Substances Identified That Were Methamphetamine in the US: 1999-2007 

- Analysis by J C Maxwell

## US Methamphetamine Indicators: 2000-2007

- Analysis by J C Maxwell

## Changes in Price of Ice: 2003-2008

- Source: DEA Quarterly Intel Reports

**$4500**

**$14,500**

## Characteristics of Clients Entering Treatment with a Primary Problem with Methamphetamine/Amphetamine:US TEDS 1993 vs. 2006

- Source: SAMHSA

## Los Angeles Treatment Admissions by Race-Ethnicity: 2007 

**SOURCE**: LA County ADP / CA ADP, California Outcome Monitoring System (CalOMS), 2007.

## Spread to Other Groups

**Mention of “La Tina” in Texas.**
**Use among day laborers, people who work long hours or several jobs (mentions from Hawaii).**
**Mexican supply line can follow the migrant trail (Rohypnol).**
**Sex trade: Reports of Hispanic women now prostituting for the drug, drug/sex trade, use among Black male prostitutes and Black MSMs. **
**Spreading in Black communities, reported more available.**
**Shifts back and forth from cocaine (powder & crack) to meth to cocaine—longer high, price, meth “more harmful than crack” but liked it.**

## Methamphetamine Admissions in

**40%**

**18%**

**3%**

**14%**

**13%**

**7%**

**31%**

**10%**

**4%**

**9%**

**Methamphetamine Admissions in**
**U.S. and Mexican Border States: 2003**

- Source: Maxwell et al.

## Amphetamine/Methamphetamine as % of Treatment Admissions in Mexico and the US

**Mexico**

**US**

- Source: Maxwell et al.

## Route of Administration of Methamphetamine Admissions to Treatment in US-Mexico Border Programs

- Source: Maxwell et al.

## Meth abusers have trouble organizing information from more than one source—can’t switch points of view. 
Paradoxical—concentration better when on meth—worse as become abstinent—learning & memory.
Comprehension deficits. Make sure they understand what counts as compliance (drug courts, CPS workers reuniting families, taking meds as scheduled). Can’t remember. Need concrete and specific information.

**Paradoxical—concentration better when on meth—worse as become abstinent—learning & memory.**
**Comprehension deficits. Make sure they understand what counts as compliance (drug courts, CPS workers reuniting families, taking meds as scheduled). Can’t remember. Need concrete and specific information.**

- Analysis by J C Maxwell

## Matrix Model

**Manualized 16 week non-residential, psychosocial approach used for the treatment of drug dependence.**
**Designed to integrate several interventions into a comprehensive approach. Elements include:**
**Individual counseling**
**Cognitive behavioral therapy**
**Motivational interviewing**
**Family education groups**
**Urine testing**
**Participation in 12-Step programs.**

## Urinalysis Results*

- Results of Ua Tests at Discharge, 6 months and 12 Months post admission **
-       _Matrix Group_		_TAU Group_
- D/C:     66% MA-free	        65% MA-free
- 6 Ms:    69% MA-free	        67% MA-free
- 12 Ms:  59% MA-free	        55% MA-free
- **Over 80% follow up rate in both groups at all points
- *Rawson, R et al Addiction vol 99, 2004**    ****	**

## DOWNERS

**Barbiturates (phenobarbital), benzos (diazepam-Valium, alprazolam-Xanax, clonazepam-Klonopin, lorazepam-Ativan, chlordiazepoxide-Librium).**
**Potentiate low-quality heroin (and seen in heroin overdoses)**
**Come down from speed or cocaine trips**
**Dependence among females.**
**Xanax from Mexico?**
**Kids like Xanax (Four Bars).**

## Club Drugs

**Problems identified early by CEWG: MDMA in 1985, GHB in 1990,Ketamine in 1991, Rohypnol in 1993, but slow responses.**
**Misperception that all club drugs are alike.**
**CEWG members report MDMA use is up. More use by Blacks, low income, sex workers. Supplies through Canada.**
**Sex risk: Ketamine, GHB (Fantasy)**

## Party Drugs Identified by U.S. Toxicology Labs: 2000-2007

- Source: NFLIS

## Texas Treatment Admissions with a Primary, Secondary or Tertiary Problem with Ecstasy: 1998-2007

- DSHS data; analysis by JC Maxwell

## Admissions to DSHS-Funded Treatment Programs With a 1st, 2nd, or 3rd Problem With a Club Drug: 2007

- Source: DSHS, analysis by JC Maxwell

## Inhalants

## % Texas Secondary Students Who Had Used Inhalants Ever or in the Past Month, by Grade: 2006

- Source: DSHS

## % Texas Secondary Students Who Had Used Marijuana Ever or in the Past Month, by Grade: 2006

- Source: DSHS

## % Texas Secondary Students Who Had Used Inhalants Ever or in the Past Month, by Grade: 2006

- Source: DSHS

## Percentage of Texas Students Who Had Ever Used Inhalants, by Grade and Number of Different Types Used: 2006

- Source: DSHS

## % Texas Reform & Secondary School Students Who Had Ever Used Specific Inhalants: 2000-2001

- Source: DSHS

## Youths 12 to 17 Who Used Inhalants and Experienced Major Depressive Episode (MDE) in the Past Year, by First Inhalant Use and First MDE: NSDUH 2004-2006

- Source: SAMHSA

## Past Year Use of Inhalants and Major Depressive Episodes (MDE): Number of Days Used: NSDUH 2004-2006 

- Source: SAMHSA

## Percent HIV Cases by Selected Modes of Exposure: Texas 1999-2007(Cases with Risk Not Classified or that Seroconverted to AIDS Excluded)

- Source: DSHS

## Percent of Texas AIDS Cases Reported by Selected Modes of Exposure: 1987-2007(Cases with Risk Not Classified Excluded)

- Source: DSHS

## Injection as Route of Administration of Clients in Texas Programs: 1988-2007

- DSHS data; analysis by JC Maxwell

## Past Year Injection Use of Heroin, Cocaine, Stimulants, or Methamphetamine among Persons Aged 12 or Older, by Race/Ethnicity NSDUH 

- Source: SAMHSA

##  Past Year Injection Drug Use among Persons Aged 12 or Older, by Geographic Characteristics: Percentages, NSDUH 2002-2005 

- Source: SAMHSA

## Route of Administration among Past Year Illicit Drug Users Aged 12 or Older: NSDUH 2002-2005 

- Source: SAMHSA

## Texas Male and Female HIV Cases by Race/Ethnicity: 1999-2007 (Cases that seroconverted to AIDS excluded)

- Source: DSHS

## Texas Male and Female AIDS Cases by Race/Ethnicity: 1999-2007

- Source: DSHS

## WWW.GCATTC.NET