BILL ANALYSIS Ó Senate Appropriations Committee Fiscal Summary Senator Kevin de León, Chair AB 446 (Mitchell) - HIV testing. Amended: July 8, 2013 Policy Vote: Health 9-0, Judic. 6-0 Urgency: No Mandate: No Hearing Date: August 30, 2013 Consultant: Brendan McCarthy SUSPENSE FILE. Bill Summary: AB 446 would revise the regulatory requirements on providers of HIV tests. Fiscal Impact: Minor anticipated costs to provide information and technical assistance to providers of HIV testing services by the Department of Public Health (General Fund). Unknown increase in HIV testing costs by the state's Medi-Cal program (50% General Fund, 50% federal funds). Under the bill, the number of Medi-Cal enrollees being tested for HIV is likely to increase, increasing program costs. Unknown increase in treatment costs for HIV positive Medi-Cal enrollees and participants in the Aids Drug Assistance Program (General Fund and federal funds). The state spends about $25,000 per year per HIV positive Medi-Cal enrollee and about $12,000 per year per HIV positive Aids Drug Assistance Program enrollee. To the extent that the bill increases testing rates, HIV positive Medi-Cal enrollees would become aware of their HIV status earlier and begin treatment earlier (current clinical guidelines recommend anti-viral treatment begin immediately upon diagnosis). Unknown long-term costs savings to Medi-Cal due to earlier medical intervention for HIV-positive Medi-Cal enrollees. To the extent that HIV-positive Medi-Cal enrollees are diagnosed earlier and begin treatment earlier, it is likely that the long-term health status of those individuals will AB 446 (Mitchell) Page 1 improve and some of the health effects of HIV will be delayed or avoided. There are indications that untreated HIV causes long-term health impacts such as elevated risk of diabetes and heart disease, even before the effects of compromised immune system function associated with HIV infection become evident. Earlier diagnosis and treatment for HIV-positive individuals is likely to reduce long-term Medi-Cal expenditures for those individuals. Background: Current law requires medical providers to provide certain information about HIV tests and HIV treatment options before providing an HIV test. In addition, the patient must provide informed consent to an HIV test. In clinical settings, a patient may provide such consent orally, but in non-clinical settings the patient must provide written informed consent before the test is administered. These requirements do not apply when the patient independently requests an HIV test. Published academic literature indicates that written informed consent requirements reduce testing rates, compared to simplified written consent procedures or oral consent requirements. Proposed Law: AB 446 would revise the regulatory requirements on providers of HIV tests. Specific provisions of the bill would: Add a new requirement that medical providers inform a patient about HIV risk reduction strategies; Clarify that an exemption from informed consent requirements in clinical settings applies if the patient requests an HIV test; Exempt HIV testing and counseling sites from the informed consent requirement if the patient requests a test; Allow informed consent to be provided by the patient orally or in writing; Require providers to ensure the recipient of an HIV test receive information on the test results in a timely manner; Require providers to inform patients who receive a positive test about treatment options; Require primary care clinics to offer an HIV test to patients under certain circumstances; Permit test results to be provided to a patient over the internet, if certain conditions are met. Related Legislation: AB 506 (Mitchell) provides social workers AB 446 (Mitchell) Page 2 with additional authority to consent to HIV testing of infants in temporary custody. The Assembly has concurred in the Senate amendments to that bill. Staff Comments: The intention of the bill is to increase the rate at which people are tested for HIV by simplifying informed consent requirements and other regulatory requirements on providers. Based on published academic literature, this is likely to increase the testing rate in the state, although the magnitude of the increase is not known. As noted above, there are likely to be increased costs to Medi-Cal from additional testing of enrollees. In the long-run, there are also likely to be costs savings to Medi-Cal, due to earlier diagnosis and treatment, which is likely to reduce overall healthcare costs for HIV-positive enrollees. In addition, there are indications that a positive HIV diagnosis dramatically reduces the chances that an HIV-positive person will transmit the virus to others, both because treatment reduces viral loads in the patient and because individuals with a positive diagnosis seem to reduce risky behavior. To the extent that increased testing informs more individuals of their HIV status, there may be a long-term reduction in infection rates.