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  








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              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  








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          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.