BILL ANALYSIS                                                                                                                                                                                                    



                                                                     AB 521


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          Date of Hearing:   April 21, 2015


                            ASSEMBLY COMMITTEE ON HEALTH


                                  Rob Bonta, Chair


          AB 521  
          (Nazarian) - As Amended April 14, 2015


          SUBJECT:  HIV testing.


          SUMMARY:  Applies existing human immunodeficiency virus (HIV)  
          testing requirements for primary care clinics to hospital  
          emergency departments (EDs), as specified. Specifically, this  
          bill:  


          1)Requires each patient who has blood drawn in a hospital ED,  
            and who has consented to an HIV test, to be offered an HIV  
            test.  Requires the test to conform with the U.S. Preventative  
            Services Task Force (USPS Task Force) recommendation.  Exempts  
            from testing if the patient was tested, or offered testing and  
            declined, within the last 12 months. Requires subsequent  
            testing to be consistent with the most recent guidelines of  
            the USPS Task Force.


          2)Allows a hospital ED to charge a patient to cover the cost of  
            HIV testing.


          3)Indicates that a hospital ED has complied with these  
            requirements if an HIV test is offered.









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          4)Requires a hospital ED to attempt to provide test results to  
            the patient prior to departure from the hospital.  Allows the  
            hospital to inform the patient of a negative result by letter  
            or telephone if the patient leaves the hospital before test  
            result is available.  Requires the hospital to inform a  
            patient with a positive test result in a manner consistent  
            with state law.


          5)Deems a hospital ED to be in compliance with existing HIV  
            testing notification and counseling requirements if they  
            provide printed material to the patient that includes the  
            following information and advice:


             a)   Timely information and counseling, as appropriate, to  
               explain the results and the implications for the patient's  
               health;


             b)   If the patient tests positive for HIV infection,  
               information that there are numerous treatment options  
               available and identify followup testing and care that may  
               be recommended, including contact information for medical  
               and psychological services; and,


             c)   If the patient tests negative for HIV infection and is  
               known to be at high risk for HIV infection, information  
               advising the patient of the need for periodic retesting,  
               explaining the limitations of current testing technology  
               and the current window period for verification of results,  
               and may offer prevention counseling or a referral to  
               prevention counseling.


          EXISTING LAW:  









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          1)Requires each patient who has blood drawn in a primary care  
            clinic, and who has consented to an HIV test, to be offered an  
            HIV test.  Requires the test to conform with the USPS Task  
            Force recommendation.  Exempts from testing if the patient was  
            tested, or offered testing and declined, within the last 12  
            months. Requires subsequent testing to be consistent with the  
            most recent guidelines of the USPS Task Force.


          2)Allows a primary care clinic to charge a patient to cover the  
            cost of HIV testing.


          3)Indicates that a primary care clinic has complied with these  
            requirements if an HIV test is offered.


          4)A primary care clinic shall attempt to provide test results to  
            the patient prior to departure from the facility.  Allows the  
            clinic to inform the patient of a negative result by letter or  
            telephone if the patient leaves the hospital before test  
            result is available.  Requires the hospital to inform a  
            patient with a positive test result in a manner consistent  
            with state law.


          5)Requires a medical care provider, after the results of an HIV  
            test have been received, to:


             a)   Ensure that the patient receives timely information and  
               counseling, as appropriate, to explain the results and the  
               implications for the patient's health;


             b)   If the patient tests positive for HIV infection, the  
               medical provider or the person who administers the test  
               shall inform the patient that there are numerous treatment  








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               options available and identify followup testing and care  
               that may be recommended, including contact information for  
               medical and psychological services; and,


             c)   If the patient tests negative for HIV infection and is  
               known to be at high risk for HIV infection, the medical  
               provider or the person who administers the test shall  
               advise the patient of the need for periodic retesting,  
               explain the limitations of current testing technology and  
               the current window period for verification of results, and  
               may offer prevention counseling or a referral to prevention  
               counseling.


          6)Requires a medical care provider, except in the event that the  
            test is independently requested and prior to ordering an HIV  
            test, that a medical care provider inform the patient that the  
            test is planned, provide information about the test, inform  
            the patient that there are numerous treatment options  
            available for a patient who tests positive for HIV and that a  
            person who tests negative for HIV should continue to be  
            routinely tested, and advise the patient that he or she has  
            the right to decline the test.  If a patient declines the  
            test, the medical care provider shall note that fact in the  
            patient's medical file.


          7)Requires informed consent by the patient or their parent,  
            guardian, conservator, or other individual specified by law,  
            before administering an HIV test, except in the event that the  
            test is independently requested from an HIV counseling and  
            testing site employing a trained HIV counselor. Informed  
            consent may be provided orally or in writing, but consent  
            shall be documented, whether obtained orally or in writing, in  
            the client's medical record.


          FISCAL EFFECT:  This bill has not been analyzed by a fiscal  








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          committee.


          COMMENTS:  


          1)PURPOSE OF THIS BILL.  According to the author, California has  
            led the way in identifying people living with HIV and linking  
            them with care and treatment.  For example, AB 446 (Mitchell),  
            Chapter 589, Statues of 2013, requires public health clinics  
            to offer an HIV test.  Until the Patient Protection and  
            Affordable Care Act has been fully implemented, EDs will  
            continue to play a critical role in delivering primary care  
            services to many new enrollees and the uninsured.  Given that  
            there are more than 5,000 new HIV infections in California  
            every year, this bill will bridge the gap in lack of HIV  
            testing by requiring EDs to uniformly provide HIV testing.


          2)BACKGROUND.  HIV is the virus that can lead to acquired  
            immunodeficiency syndrome, or AIDS. Unlike some other viruses,  
            the human body cannot get rid of HIV.  That means that once  
            you have HIV, you have it for life.  No safe and effective  
            cure currently exists, but scientists are working hard to find  
            one, and remain hopeful.  Meanwhile, with proper medical care,  
            HIV can be controlled.  Treatment for HIV is often called  
            antiretroviral therapy or ART. It can dramatically prolong the  
            lives of many people infected with HIV and lower their chance  
            of infecting others.  Before the introduction of ART in the  
            mid-1990s, people with HIV could progress to AIDS in just a  
            few years.  Today, someone diagnosed with HIV and treated  
            before the disease is too far advanced can have a nearly  
            normal life expectancy. HIV affects specific cells of the  
            immune system, called CD4 cells, or T cells.  Over time, HIV  
            can destroy so many of these cells that the body can't fight  
            off infections and disease.  When this happens, HIV infection  
            leads to AIDS.  According to the California Department of  
            Public Health (DPH), Office of AIDS, in California there were  
            119,878 living cases of HIV (AIDS and non-AIDS) as of December  








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            31, 2013.


          3)SUPPORT.  According to the sponsor, the AIDS Healthcare  
            Foundation (AHF), despite dramatic advances in treatment  
            options, this epidemic is far from over.  There are more than  
            5,000 new infections in California every year.  According to  
            DPH, 16% of Californians who are HIV-positive do not know they  
            are HIV-positive and thus are not getting treatment and  
            unwittingly expose uninfected people to HIV; that number jumps  
            to 58% for young people, up to age 24.  The more than 20,000  
            Californians who do not know they are HIV-positive are causing  
            70% of the new infections, while the 84% of Californians who  
            are aware they are HIV-positive only cause 30% of new  
            infections.



          AHF continues, this bill simply requires the offer of an HIV  
            test in an ED if blood is already being drawn for another  
            purpose.  AHF writes that they recognize that EDs are  
            constantly under pressure to meet the immediate needs of their  
            patients.  AHF concludes, this bill seeks to balance the  
            public health demands of controlling this epidemic with the  
            operational needs of an ED.  AHF points at the Emergency Room  
            as the last remaining major source for the identification of  
            new people with HIV. 
          4)OPPOSITION.  In opposition, the California Chapter of the  
            American College of Emergency Physicians (Cal/ACEP) argues  
            that while this bill may appear to be an easy and efficient  
            way to increase HIV diagnosis and treatment, it is  
            unfortunately extremely problematic.  Although fewer than 5%  
            of doctors are emergency physicians, they handle a quarter of  
            all acute care encounters and more than half of acute care  
            visits by the uninsured.  Diagnosing and treating HIV is an  
            important public health endeavor, but EDs are not the proper  
            venue for a diagnostic public health campaign.  According to  
            Cal/ACEP, this bill would place additional stress on  
            California's overcrowded and burdened EDs, while diverting  








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            precious time away from patients with critical conditions  
            toward public health screening.  Emergency physicians estimate  
            they draw blood from 50%of their 12 million patients per year.  
            If adding an HIV test only took an additional five minutes  
            that would result in an additional 30 million minutes, or 57  
            years, of care each year. Additionally, this bill provides no  
            funding for the test itself thereby placing another unfunded  
            mandate on EDs.


          5)COMMITTEE COMMENT.  The opposition has raised concerns about  
            the difficulty obtaining consent from those unable to provide  
            it, such as from a patient with a severe injury, illness,  
            mental disturbance, or some other factor.  The Committee may  
            recommend that this bill be amended to waive the requirement  
            that an HIV test be offered when the patient is unresponsive,  
            unconscious, incapacitated, or otherwise unable to consent to  
            the test.





          6)PREVIOUS LEGISLATION


             a)   AB 446 changes state HIV testing law requiring primary  
               care clinics to offer an HIV test when taking a blood draw,  
               upon the informed consent of the patient.

             b)   AB 1894 (Krekorian), Chapter 631, Statutes of 2008,  
               requires health care service plans and disability insurers  
               selling health insurance to offer testing for HIV  
               antibodies and AIDS, regardless of whether the testing is  
               related to a primary diagnosis.












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          REGISTERED SUPPORT / OPPOSITION:




          Support


          AIDS Healthcare Foundation (sponsor)




          Opposition




          California Chapter of the American College of Emergency  
          Physicians (Cal/ACEP)
          California Hospital Association
          California Medical Association


          Analysis Prepared by:Max Mikalonis / HEALTH / (916) 319-2097