Overview of HIV/AIDS in the Texas-Mexico Border Region

Date of Report: 09/2006

The Border Defined

There are some challenges defining what constitutes the U.S. Mexico Border. The U.S. Mexico Border has at least three different definitions. The federal definition of the border, currently used by the U.S. Mexico Border Health Commission, encompasses 100 kilometers (62 miles) north and south of the international boundary. The U.S. Mexico border area comprises 2 sovereign nations, 4 states in the United States and 6 in Mexico, 44 counties in the U.S. and 80 municipalities ("municipios") in Mexico, as well as 14 sister cities in Mexico. ¹ According to the 2000 U.S. Census, 41 out of 44 border counties are medically underserved areas and half of the 44 counties are economically distressed areas. ² This federal definition covers the 32 Texas counties that lie within 100 kilometers of the Rio Grande River.

32 Texas Border Counties Brewster Brooks Cameron Crockett Culberson Dimmit Duval Edwards El Paso Frio Hidalgo Hudspeth Jeff Davis Jim Hogg Kenedy Kinney LaSalle Maverick McMullen Pecos Presidio Real Reeves Sutton Starr Terrell Uvalde Val Verde Webb Willacy Zapata Zavala

The original definition of the U.S. Mexico Border Health Commission incorporates the 26 U.S. counties that share borders with Mexico. Although Willacy County is not immediately adjacent to the border, it is included in the definition, making a total of fifteen Texas counties in this definition. Similarly, the U.S. Mexico Border Counties Coalition defines the border by the counties immediately adjacent to the U.S./Mexico border. However, its definition only includes 24 counties but includes the 15 Texas counties immediately adjacent to the border. ³ The State of Texas defines the border region as 43 counties, from El Paso to the north side of Corpus Christi on the Texas Gulf. ⁴

For the purpose of this resource directory, the border is defined under the federal definition.

Introduction and Demographics

The Texas border with Mexico is a transitional area with characteristics different from the State of Texas as a whole. The region has many environmental factors that affect the health of the residents in the area including lack of proper sanitation and air pollution from "maquiladoras". The maquiladoras operate under a special customs status that allows them to import raw materials duty free into Mexico to assemble or manufacture for subsequent export into the United States. The maquiladoras are key employer industries in border economies closely linked with manufacturing, retail trade, transportation and warehousing. ⁵

Frequent border crossings, poverty, unemployment and lack of access to health care compound this health care challenge. Residents along the U.S.-Mexico Border experience health problems commonly found in less developed nations, such as respiratory and gastrointestinal diseases and Tuberculosis. Border residents also face health issues common to the rest of the U.S., such as cancer, heart disease and diabetes.

There are approximately 13 million American and Mexican residents in the border area. ⁶ Ninety five percent (95%) of the population live in sister communities with those living on the United States side of the border living well below the poverty line. ⁷ About 19% of the U.S. border residents live below the federal poverty level, as compared to 13% of the entire U.S. population.

The border population is primarily Hispanic, mostly of Mexican descend. The 2000 U.S. Census reported a Hispanic population in the four U.S. Border Metropolitan Statistical Areas (MSA) ranging from 76% to 95%. Starr County had a Hispanic population of 96% and Hidalgo and Cameron counties, the two poorest counties in the nation, had a Hispanic population of 88% and 84%, respectively.

According to the U.S. Census 2004 population estimates, the U.S. Mexico Border had a population of over 6,885,478, of which 2.3 million, or 34% percent of the population resided in Texas border counties.

Compared to the rest of the nation, the U.S. Mexico Border has a larger share of its residents under the age of 18. According to the 2000 U.S. Census, 26 of the 32 Texas counties have a significant portion of their population under the age of 18, ranging between 28%-35%. ⁸ The other six counties have one out of every four residents under the age of 18. The average educational level of the U.S. border residents is lower than the national average.

It is estimated that there are 1 to 5 million Migrant and Seasonal Farm workers (MSFW) in the United States, of which, Texas houses 200,000 (Perkins, Zavaleta, Mudd, Bollinger, & Cisneros, J., 2001). Four border counties in particular, Cameron, Hidalgo, Willacy and Starr account for almost 30 percent of this population (Larson, 2000). This region is largely rural with the largest populations residing in major ports of commerce and trade. MSFW population in Texas are difficult to estimate given that seasonal farm workers go from Texas to other parts of the country to work. Many of these individuals also work agricultural jobs in Texas during the "off season" for work in other areas.

More than one third of families on the U.S. side of the border have incomes at or below the Federal poverty levels. Average household income for the 32 border county area varied from a low of $18,553 in Zavala County to a high of $41,283 in Sutton County. ⁹

In 1999, about one in three border residents (29%) lived in poverty. ¹⁰ During 2003, one in four border residents lived in poverty compared to 1 out of every 6 residents in the state. ¹¹ Thirty-two percent (32%) of Texas school children ages 5-17 lived in poverty in the 32 Texas border counties compared to 21% of school children in Texas for this same period. ¹²

Health care, as well as disease control, is challenging in this region, due to the fluidity of the population and limited resources are allocated for those purposes. Some individuals live in Mexico and work daily in Texas, while others visit sporadically for medical care or other needs. Many Texans conduct business or visit in Mexico. 'Colonias' neighborhoods along the Texas border are similar in their lack of basic services to impoverished neighborhoods in Mexico. It is difficult to determine the degree of self-treatment that occurs for various diseases in Texas border areas for several reasons. Laws concerning the sale of pharmaceuticals normally prescribed in Texas are generally more liberal in Mexico. In addition, Mexican physicians and dentists provide treatment and care with less restrictions and regulations than in the states. There is a pharmaceutical, medical and dental tourism in Mexico due to is cost, accessibility and availability.

Highlights of Health Issues

Economically distressed areas similar to the Texas-Mexico border region often lack sufficient private and public investments to strengthen and develop their public health infrastructure. Elements that contribute to the vulnerability of the region's health system include increased immigration, population growth, and limited or non-existent health insurance. It is estimated that close to 35% of border residents, 1 in 3 residents, lack health insurance. A study conducted by the Texas Comptroller in April 2005 found that of the four MSAs along the U.S. Mexican Border: (1) Laredo, (2) El Paso and (3) Bronwsville-Harlinger-San Benito had the highest rates of uninsured in the State at 36%, 33.2% and 32.4%, respectively, compared to the U.S. average of 15.1% and the State uninsured average of 24.7%. ¹³ The fourth border MSA, McAllen-Edinburgh-Mission MSA followed closely at 27.8%. According to the Health Resources and Services Administration (HRSA), one third of the border residents reside in areas designated as Health Professional Shortage Areas. ¹⁴

It is important to note that the three MSAs with the highest percent of uninsured also had the lowest wages in Texas. In 2003, the Border MSAs had the highest percent of their population at 200% of federal poverty levels. For instance, in Laredo 63% of its population was living below 200% of poverty. ¹⁵

Much of the border area is rural, and over half of the border counties have no hospital. Sixty five percent (65%) of the available acute care facilities are located in four MSAs, and the majority of the rural hospitals has few beds and provides limited services. The travel distance range from 11 to 78 miles in counties with an acute care facility. ¹⁶ , ¹⁷ There are only six public health departments for the entire 32 border county region. These health departments are responsible for enforcing regulations that protect the public's health, behavioral health services such as substance abuse and mental health services, emergency preparedness and prevention services, as well as assuring access to care and direct care safety net services. These health department services may also include family planning, county indigent health services and primary care services.

The U.S. Mexico border is considered the busiest crossing in the world. As such, the region is susceptible to the movements of infectious disease such as tuberculosis, sexually transmitted infections, HIV, hepatitis, shigellosis, as well as other infectious diseases. In 2005, the tuberculosis (TB) incidence rate for the 14 Texas counties immediately adjacent to the border (12.3 per 100,000) was twice that of non-border counties (6.1 per 100,000) and almost the State as whole (6.7 per 100,000). ¹⁸ The U.S. Mexico Health Commission estimates that the TB rate on the border is 70% above the national average. To track and diagnose TB is difficult because cases are only counted if individuals are living, diagnosed and continue to receive treatment for three months in the same county of residence. According to the Texas Department of State Health Services, 63% of the TB cases diagnosed in El Paso during 2004 were foreign born. ¹⁹

According to the U.S. Mexico Health U.S. Mexico Health Commission, the diabetes death rate on the U.S. side of the border for 2000 was 26.9 per 100,000. It is estimated that 4,000 border residents die from diabetes each year, with about 1,500 deaths in the U.S. side of the border. Diabetes is the third leading cause of death on the Mexico border, sixth leading cause of death on the U.S. side of the border. Heart disease is the leading cause of death on both sides of the border. ²⁰

Between 1995 and 1997 the leading causes of death in this region were heart disease, cancer, stroke, and diabetes (Pan American Health Organization, 2000). Compared to the rest of the state, death rates from hepatitis and diabetes mellitus are also higher for this region -- border region,13.4 and 33.5 per 100,000, state -- 10.0 and 24.8 per 100,000 respectively. An 18-year study analyzing death causes among persons living in four specific border counties, found that heart disease, cancer, stroke, injuries, chronic obstructive pulmonary disease (COPD), and diabetes contributed to 82% of all deaths (Perkins et al., 2001). Infectious diseases such as tuberculosis, hepatitis A, and shigellosis are also significant.

HIV/AIDS Statistics

County Population People Living with HIV/AIDS New HIV Cases Cumulative HIV Cases New AIDS Cases Cumulative AIDS Cases Texas 22,490,022 51,600 4,034 21,577 3,236 64,907 32 Border Counties 2,335,967 2,624 145 949 190 2,921 % on the Border 0.1 0.05 0.04 0.04 0.06 0.05 Brewster 9,226 1 0 0 0 6 Brooks 7,753 6 1 2 1 7 Cameron 371,825 501 42 185 37 491 Crockett 3,950 1 0 0 0 3 Culberson 27,727 1 0 1 0 1 Dimmit 10,221 4 1 2 1 8 Duval 2,013 7 1 3 0 7 Edwards 2,013 1 0 0 0 3 El Paso 713,126 1,271 70 440 64 1,471 Frio 16,386 3 0 2 1 5 Hidalgo 658,248 649 50 260 60 605 Hudspeth 3,300 1 1 1 0 0 Jeff Davis 2,253 0 0 0 0 1 Jim Hogg 5,062 0 0 0 0 3 Kenedy 407 0 0 0 0 0 Kinney 3,337 2 0 1 0 3 LaSalle 5,945 3 0 0 0 6 Maverick 50,436 33 2 12 2 48 McMullen 853 0 0 0 0 0 Pecos 15,949 5 0 1 0 11 Presidio 7,639 2 0 0 1 4 Real 2,995 1 0 0 0 1 Reeves 11,842 7 0 2 1 14 Starr 59,832 31 7 17 3 29 Sutton 4,097 2 0 1 0 1 Terrell 957 0 0 0 0 0 Uvalde 26,616 9 0 2 0 17 Val Verde 47,410 12 0 4 0 23 Webb 219,464 249 9 102 16 281 Willacy 20,231 28 1 11 0 22 Zapata 13,154 5 0 2 0 6 Zavala 11,700 5 2 0 0 6 Texas HIV/STD Surveillance Report: Texas HIV/STD Surveillance Report: Texas Department of Health, HIV/STD Epidemiology Division Surveillance Branch, 2005. Population: U.S. Census Bureau. 2004 estimates. * 2003 Surveillance data may differ from that previously reported since it is continuously updated by the TX Department of State Health Services. (Communications with TX DSHS, May 4, 2006) Population: U.S. Census Bureau. 2004 estimates.

Texas AIDS Statistics

As of December 31, 2004, the overall AIDS rate for Texas was 14.6 AIDS cases per 100,000 population, down from 17 in 2003. The male case rate (22.4/100,000) continues to be much higher than for women (6.8/100,000). The total number of AIDS cases reported in 2004 was 3,236 (2,475 males and 761 females) and in 2003 was 3,708 (2,876 males and 832 females). ²¹ . ²²

According to the Texas Department State Health Services' (DSHS) 2004 Annual Reports, African American men's proportion of AIDS went down from 34% in 2003 to 28% in 2004. Whites and Hispanic proportion also decreased during the same period, from 36% and 28% and 29% and 23%, respectively. Although White men had the highest number of AIDS cases, African American men represented the highest case rate per 100,000 population. In 2004, African American males AIDS case rate was 70 per 100,000 population.

The 2004 case rate for African American women in Texas was 35.8/100,000 population compared to 2.3/100,000 and 3.9/100,000 for White and Hispanic women, respectively. African American women in Texas represent 62% of cases among females for 2004. Women's AIDS proportions have been changing constantly, the proportion of women with AIDS went down from 2003 to 2004 for Whites (20% to 13%), African Americans (61% to 49%) and Hispanics (18% to 15%). ²³

Texas HIV Statistics

A total of 4,034 HIV cases were reported in 2004 a decrease from 4,802 were reported in 2003. Males accounted for 3,536 of the cases in 2003 and 3,066 in 2004. Female accounted for 1,266 of the 2003 cases and 968 of the 2004 cases. Although the number of HIV cases reported in males was highest in White men when compared to all other races and ethnic groups, African American males had four times the HIV case rate (83.9/100,000) than any other race and ethnicity (Whites 22/100,000 and Hispanics 19.8/100,000).

There was an increase in HIV cases among women from 2000 to 2004; African American women reported three times the number of White and Hispanic cases. According to the 2004 DSHS' Annual Reports, as of December 31, 2004, there were 51,600 people living HIV/AIDS (PLWHA) in Texas. African Americans have the highest HIV case rate (46.1/100,000) among all other racial and ethnic groups (Whites 3.3/100,000 and Hispanics 4.2/100,000). Those numbers change on the border for those populations. According to the Texas Department of State Health Services the HIV case rate for 2003 was reported as 9.8 per 100,000 for the 32 Texas border counties. ²⁴

U.S. Mexico Border County HIV/AIDS

Sexually transmitted infections (STI) are prevalent on the border. Ten percent of the Chlamydia cases diagnosed in Texas during 2004 were diagnosed in the 32 Texas border counties. ²⁵ Research has shown than individuals who are infected with STIs are more likely than uninfected individuals to acquire HIV if they are exposed to HIV through sexual contact. In addition, if an HIV-infected individual is also infected with another STI, that person is more likely to transmit HIV through sexual contact than other HIV-infected persons (Wasserheit, 1992).

HIV and AIDS prevalence in the Texas border counties is lower than in other parts of the State. It is not clear, however, to what extent these lower prevalence may reflect lower rates of testing, the transient nature of border residents and binational patients, or possibly a lack of effective case-finding and outreach strategies for HIV counseling and testing services along the border. ²⁶

AIDS

During 2004, there were 190 new AIDS cases diagnosed within the 32 Texas border county region, of which 188 were reported in the 15 counties immediately adjacent to the Mexican Border (Brewster, Cameron, El Paso, Hidalgo, Hudspeth, Jeff Davis, Kinney, Maverick, Presidio, Starr, Terrell, Val Verde, Webb, Zapata and Willacy). ²⁷ AIDS cases diagnosed in the 32 border counties represent 6% of the total number of cases for the State.

Hispanics on the border account for the majority of the population and the number of AIDS cases (86%) in 2004. Men are disproportionately being affected since they accounted for less than half of the population but represent 80% of the AIDS infected population. M/MS is also reported as the main mode of exposure (43%), followed by F/MS (23%) and IDU (13%). Substance abuse along the border is a growing problem. Field research shows that heroin is the number one drug of choice in the region, but methamphetamine use is growing. ²⁸

HIV

As of December 31, 2004 there were 2,624 PLWHA in the border area. Hispanics had the largest number of PLWHA, however the number of cases reported by DSHS have slightly declined each year for all racial/ethnic groups. Among mode of exposure, M/MS accounted for more than half (56%) of living with HIV cases as of December 31, 2004.

The cumulative number of HIV cases for the 32 Texas border counties for this same time period was 949. M/MS is the primary mode of HIV exposure (46%) and F/MS and IDU follows with 14% and 13% HIV cases, respectively.

U.S. Mexico Border Steering Team (UMBAST)

UMBAST is a working group that encompasses the three U.S./Mexico border AIDS Education and Training Centers ? Texas/Oklahoma, Mountain Plains & Pacific, as well as Health Resources and Services Administration's representatives that serve the U.S. Mexico Border. The mission of UMBAST is to promote high quality culturally sensitive education and capacity building programs for clinicians and agencies that provide HIV/AIDS related prevention and clinical management services in the U.S./Mexico border region.

U.S. Mexico Border HIV/AIDS Challenges

There are millions of border crossings each year: from binational tourism, individuals returning home for the winter after working across the border, to individuals going into Mexico to purchase pharmaceuticals. More liberal laws on prescription drugs and self-medication impact the treatment and care of individuals with HIV infection. Self-treatment and migratory patterns lead to medication resistance and other HIV management complications. Binational collaboration that provides an infrastructure for enhanced systems of care is needed. This will ensure that care is not interrupted or duplicated.

HIV testing needs to continue to be incorporated in routine prenatal protocols to prevent perinatal transmission. For mothers of unknown HIV status at the time of delivery, rapid testing plays an important role in the prevention of HIV transmission to the newborn baby. Training and capacity building should be provided to ensure that hospitals and birthing places are aware of appropriate prophylaxis for newborns exposed to HIV.

Individuals along the border, especially in Eagle Pass and Laredo, must travel long distances to access HIV care. Providers in Eagle Pass report transporting individuals with HIV to San Antonio, 150 miles outside of the border, for HIV border residents to access HIV care. This creates a fragmented service delivery since individuals are unable to be linked to other ancillary services so far away from their residence.

U.S. Mexico Border HIV/AIDS Trends

	Increased multiple social service needs due to millions of border crossings per year. Many residents live in areas without basic necessities such as potable water and sewer systems, electricity, paved roads ad safe and sanitary housing.
	Hispanics on both sides of the border face significant barriers accessing HIV services and maintaining continuity of care.
	PLWHA experience difficulty accessing specialty providers and often must travel great distances to urban areas for services. 29
	The rate of tuberculosis on the U.S. side of the border is 70% above the national average.
	Balancing increasing needs for funding for new drug therapies and early treatment guidelines with continuing needs for support services.
	Need for extensive patient education in learning how to properly comply complex HIV therapies to decrease drug resistance.
	Need for minority and minority serving HIV and specialty providers reflective of the service population.
	Build capacity among health care practitioners to manage the care of a mobile HIV border population.
	Binational policies are needed to facilitate HIV care and programming for the border mobile population.
	Concerns over confidentiality and stigma keep people from getting tested for HIV or seeking care of infected.
	The area is faced with increase birth rates, diabetes, hepatitis and higher rates of uninsured residents.
	Women and people of color continue to show the steepest trends of HIV/AIDS.
	Limited substance abuse services make untreated addiction a barrier to dealing with HIV disease.
	Hepatitis A is two to three more prevalent along the border than in the United Sates as a whole.

Public Health Regions

There are four Texas Department of State Health Services' Public Health Regions (PHR) within the U.S. side of the border. These regions include PHR 8, 9, 10 and 11. Six local health departments serve this 32 county border area.

Public Health Region 8

According to Texas DSHS's 2004 report, there are 71 PLWHA in Public Health Region 8 border counties. Out of 10 counties included in the border region (Dimmit, Edwards, Frio, Kinney, La Salle, Maverick, Real, Uvalde, Val Verde, and Zavala), Maverick county has the greatest number of PLWHA with, 11 HIV cumulative cases and 46 AIDS cumulative cases.

Public Health Region 9

Crockett, Pecos, Reeves, Sutton and Terrel Counties are the border counties in PHR 9. In comparison to the other border regions, PHR 9 has the smallest population and fewer numbers of PLWHA (N=14).

Public Health Region 10

The Public Health Region 10 includes Brewster, Culberson, El Paso, Hudspeth, Jeff Davis and Presidio border counties. According to TSDHS epidemiology, the region had 1,204 PLWHA in the region. As of December 31, 2004, all HIV and AIDS cases reported for PHR 10 border counties were reported in El Paso County, except for 11 cases. ³⁰

Public Health Region 11

Public Health Region 11 is located in south Texas with the largest number of border counties on the entire Texas/Mexico border. Eleven of the 32 border counties are part of PHS Region 11 - Brooks, Cameron, Duval, Hidalgo, Jim Hogg, Kenedy, McMullen, Starr, Webb, Willacy, and Zapata. As of the end of 2004, these PHR region 11 border counties reported a total of 1,367 PLWHA. Three of the four border counties with the largest population and greatest number of PLWHA are located in Region 11 - Webb, Hidalgo and Cameron counties.

References, Resources, and Links

	Healthy Border 2010 Program . Healthy People 2010 is a national health promotion and disease prevention initiative that brings together national, State, and local government agencies; nonprofit, voluntary, and professional organizations; businesses; communities; and individuals to improve the health of all Americans, eliminate disparities in health, and improve years and quality of healthy life.
	Overview of Epidemiological Data . 2004 Texas Statewide Coordinated Statement of Need (SCSN) Report. Texas Department of Health.
	HIV/STD Epidemiology Division, Surveillance Branch, 2004 Annual Report . Texas Department of State Health Services.
	Texas HIV/AIDS and STD 2001 Border Report . HIV/STD Epidemiology Division, Bureau of HIV and STD Prevention, Texas Department of Health.
	Texas Department of Health, Bureau of HIV and STD Prevention, Training and Public Education Branch . Site includes listings of trainings and conferences, educational materials, and other resources.
	List of Hospitals in the Texas/Mexico Border Region
	Map of Counties that are eligible to participate in the Economically Distressed Areas Program
	Texas Department of Health HIV/STD Program
	Border Activity Tracker (BAT)
	Pan American Health Organization
	Texas Health Service Regions 9 and 10
	US/Mexico Border Counties Coalition
	HIV/AIDS Regional Resource Network Directory
	National Association of Community Health Centers
	Texas Association of Community Health Centers

Acknowledgments

Overview and resource listings prepared by Oscar González, Border Coordinator and Mae Rupert, Evaluation Coordinator for the Texas/Oklahoma AETC. Comments provided by Laura Armas-Koloustroubis, M.D., Clinical Director and Henry Pacheco, M.D., Director Texas/Oklahoma AETC.

References

1.		U.S.-Mexico Border Health Commission - Border Region.
2.		U.S.-Mexico Border Health Commission Assessment, OMB, ExpectMore.gov, 2005.
3.		At The Crossroads: U.S.-Mexico Border Counties in Transition, U.S.-Mexico Border Counties Coalition, March 2006.
4.		Bordering the Future: Challenges and Opportunity in the Texas Border Region, July 1998, John Sharp, Texas Comptroller of Public Accounts.
5.		At the Cross Roads: U.S.-Mexico Border Counties in Transition, U.S./Mexico Border Counties Coalition, March 2006, pages 6-25.
6.		U.S.-Mexico Border Counties Coalition. U.S.-Mexico Border Health.
7.		Centro de Evaluación, U.S.-Mexico Border Health Evaluation and Technical Assistance Center, May 2001.
8.		U.S. Census 2000.
9.		Small Area Income and Poverty Estimates, U.S. Census Bureau.
10.		U.S. Census, State and County Quick Facts, Persons below poverty, percent 1999.
11.		U.S. Census, Small Area Income Poverty Estimates, estimates for Texas counties, 2003.
12.		U.S. Census, Small Area Income Poverty Estimates, estimates for Texas counties, 2003.
13.		The Uninsured: A Hidden Burden on Texas Employers and Communities, April 2005, Office of the Comptroller, Texas.
14.		Women's Health U.S.A 2005, Department of Health and Human Services, Health Resource and Services Administration, 2005.
15.		The Uninsured: A Hidden Burden on Texas Employers and Communities, April 2005, Office of the Comptroller, Texas.
16.		Spatial and Economic Access to Acute Care Facilities for Rural Women Along the Texas-Mexico Border, Cruz. C Torres, Ph.D., R.N., 2002 Rural Women Health Conference.
18.		Number of Tuberculosis Cases for the 14 Texas-Mexico Border Counties 2001-2005, Texas State Department of State.
19.		Percentage of Tuberculosis Cases with Risk Factors by Selected Counties, Texas 2004.
20.		U.S.-Mexico Border Health Commission Assessment, OMB, ExpectMore.gov, 2005.
21.		2004 Annual Report: HIV/STD Surveillance Report, HIV/STD Epidemiology and Surveillance Branch, Texas Department of State Health Services.
22.		HIV/STD 2004 Annual Report, Texas Department of Health Services, HIV/STD Epidemiology and Surveillance Branch.
23.		2004 Annual Report: HIV/STD Surveillance Report, HIV/STD Epidemiology and Surveillance Branch, Texas Department of State Health Services; and 2003 Annual Report: HIV/STD Surveillance Report, HIV/STD Epidemiology and Surveillance Branch, Texas Department of Health.
24.		2004 Annual Report: HIV/STD Surveillance Report, HIV/STD Epidemiology and Surveillance Branch, Texas Department of State Health Services; and HIV/STD Program 2004 Annual Report, Department of State Health Services.
25.		2004 Annual Report: HIV/STD Surveillance Report, HIV/STD Epidemiology and Surveillance Branch, Texas Department of State Health Services.
26.		2004 Border Summit, White Paper: A Disease Without Borders: The Impact of HIV and Migration on Families Living along the U.S.-Mexico Border, May 2005, TX/OK AETC.
27.		2004 Annual Report: HIV/STD Surveillance Report, HIV/STD Epidemiology and Surveillance Branch, Texas Department of State Health Services.
28.		Field Ethnographic Observations, Oscar González, MS, Border Coordinator, December 2004 - May 2005, TX/OK AETC.
29.		Texas Statewide Coordinated Statement of Need 2006-2007.
30.		2004 Annual Report: HIV/STD Surveillance Report, HIV/STD Epidemiology and Surveillance Branch, Texas Department of State Health Services.