BILL ANALYSIS                                                                                                                                                                                                    

                          Senator Ed Hernandez, O.D., Chair

          BILL NO:                    AB 521    
          |AUTHOR:        |Nazarian                                       |
          |VERSION:       |June 29, 2015                                  |
          |HEARING DATE:  |July 8, 2015   |               |               |
          |CONSULTANT:    |Melanie Moreno                                 |
           SUBJECT  :  HIV testing.

           SUMMARY  :  Requires a patient who has been admitted as an inpatient to a  
          hospital through the emergency department and has blood drawn  
          after being admitted to the hospital, and who has consented, to  
          be offered an HIV test.
          Existing law: Requires each patient who has blood drawn at a  
          primary care clinic, and who has consented, to be offered an HIV  
          test, consistent with the United States Preventive Services Task  
          Force (USPSTF) recommendation for screening the HIV infection. 
          This bill: 
          1)Requires a patient who has been admitted as an inpatient to a  
            hospital through the emergency department (ED) and has blood  
            drawn after being admitted to the hospital, and who has  
            consented, to be offered an HIV test. 

          2)Prohibits the ED from being responsible for offering an HIV  

          3)Requires the hospital clinician to offer an HIV test  
            consistent with the USPSTF recommendation for screening HIV  

          4)Makes related technical, conforming changes to existing law.  

          EFFECT  :  According to the Assembly Appropriations Committee:

          1)Assuming this ED testing mandate identifies 150 individuals  
            eligible for treatment through state programs, including  
            Medi-Cal and  the AIDS Drug Assistance Program (ADAP), and  


          AB 521 (Nazarian)                                  Page 2 of ?
            that 65% of those are linked to care, state costs as follows: 

               a)  Potential Medi-Cal costs (in fee-for service Medi-Cal)  
                 or cost pressure (in managed    care) of $450,000  
                 (General Fund (GF)/federal) for increased testing. 

                      b)  $650,000 annually (GF/federal) to Medi-Cal for  
                 increased HIV/acquired immune            deficiency  
                 syndrome (AIDS) treatment costs.

               c)   $250,000 annually (potential GF/federal) to the ADAP  
                   and the Office of AIDS Health Insurance Premium Program  
                   (OA/HIPP) for increased HIV/AIDS treatment costs, on a  
                   net basis. 

            Costs are potentially offset by unknown long-term state cost  
            avoidance by identifying HIV infection and beginning treatment  
            earlier before significant medical complications arise, and by  
            potentially preventing additional transmission.  Currently,  
            about 5,000 people are newly diagnosed with HIV in California  
            every year.

          VOTES  :  
          |Assembly Floor:                     |51 - 21                     |
          |Assembly Appropriations Committee:  |12 - 5                      |
          |Assembly Health Committee:          |13 - 5                      |
          |                                    |                            |
          COMMENTS  :
          1)Author's statement.  According to the author, over the past  
            decade, California has focused on the need to test, as early  
            as possible, to reduce HIV infection rates and link people  
            with HIV treatment.  Given that there are more than 5,000 new  
            HIV infections in California every year, AB 521 will bridge  
            the gap in lack of HIV testing by requiring hospitals to offer  
            an HIV test to patients that have been admitted via the  
            emergency department. The ED trigger is key, as emergency  
            rooms will continue to play a critical role in delivering  


          AB 521 (Nazarian)                                  Page 3 of ?
            primary care services to many new enrollees and to those who  
            remain uninsured. AB 521 recognizes that emergency rooms  
            continue to play a vital role in helping to identify  
            individuals with HIV. 
          2)Background. According to a 2015 CDC report, an estimated  
            1,148,200 persons aged 13 years and older are living with HIV  
            infection.  Over the past decade, the number of people living  
            with HIV has increased, while the annual number of new HIV  
            infections has remained relatively stable. Still, the pace of  
            new infections continues at far too high a level, particularly  
            among certain groups.   The estimated incidence of HIV has  
            remained stable overall in recent years, at about 50,000 new  
            HIV infections per year. Within the overall estimates,  
            however, some groups are affected more than others. Men who  
            have sex with men (MSM) continue to bear the greatest burden  
            of HIV infection, and among races/ethnicities, African  
            Americans continue to be disproportionately affected.  In  
            2013, an estimated 47,352 people were diagnosed with HIV  
            infection in the United States. In that same year, an  
            estimated 26,688 people were diagnosed with AIDS. Overall, an  
            estimated 1,194,039 people in the United States have been  
            diagnosed with AIDS. An estimated 13,712 people with an AIDS  
            diagnosis died in 2012, and approximately 658,507 people in  
            the United States with an AIDS diagnosis have died overall.  
            The deaths of persons with an AIDS diagnosis can be due to any  
            cause-that is, the death may or may not be related to AIDS.

          3)HIV positive but unaware.  According to the CDC, of the nearly  
            1.2 million people estimated to be living with HIV in the US,  
            nearly one in seven (more than 168,000) do not know they are  
            infected. According to the California Office of AIDS, as of  
            the end of 2011, it is estimated that between 29,523 and  
            31,948 HIV-positive and unaware individuals reside in  
            California. Because many new infections are transmitted by  
            people who do not know they are infected, undiagnosed  
            infection remains a significant factor fueling the HIV  
            epidemic. According to the CDC, when HIV is diagnosed early,  
            appropriately timed interventions, particularly highly active  
            antiretroviral therapy, can lead to improved health outcomes,  
            including slower clinical progression and reduced mortality.   
            Additionally, HIV counseling with testing has been  
            demonstrated to be an effective intervention for HIV-infected  
            participants, who increased their safer behaviors and  
            decreased risk behaviors. 


          AB 521 (Nazarian)                                  Page 4 of ?

          4)Double referral.  This bill has been double referred.  Should  
            this bill pass out of this committee, it will be referred to  
            the Senate Judiciary Committee.

          5)Prior legislation. AB 446 (Mitchell, Chapter 589, Statues of  
            2013), among other provisions related to consent for HIV  
            testing, requires community clinics to offer an HIV test.  

          6)Support.  According to the sponsor, the AIDS Healthcare  
            Foundation (AHF), Californians who are HIV-positive but do not  
            know they are HIV-positive are not getting treatment and  
            unwittingly expose uninfected people to HIV, and 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 states that this bill's provisions  
            are triggered by a person's admission to the hospital through  
            an ED because many people who are served in an ED reflect the  
            demographics that are often missed in other HIV screening  
            programs.  AHF contends that if the state is to ever get full  
            control of the HIV epidemic, it must reach the people it is  
            not reaching now, and a focal point for engaging those people  
            is through ER-admissions to the hospital. AIDS Project Los  
            Angeles writes that a recent CDC analysis showed that 90% of  
            new HIV infections could be prevented by diagnosing people  
            living with HIV and linking them with ongoing care and  
            treatment and this bill will help identify Californians living  
            with HIV, link them to care, and help prevent the spread of  
            the disease.
          7)Opposition.  The California Hospital Association (CHA) states  
            that this bill presents operational and capacity challenges  
            for acute care hospitals as hospitals would be required to  
            comply with Health and Safety Code Section 120990, which  
            details the informed consent process for HIV testing. Staff  
            time will be required to explain the test and why it is being  
            offered, and to obtain the patient's consent or refusal. CHA  
            states that this bill is another unfunded mandate potentially  
            increasing costs to hospitals and creates a time-consuming  
            process that will divert staff time and resources away from  
            in-patient care.  
          Support:  AIDS Healthcare Foundation (sponsor)


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                    AIDS Project Los Angeles
                    Beyond AIDS 
                    The Wall Las Memorias Project
                    Numerous individuals
          Oppose:   California Hospital Association

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