BILL ANALYSIS Ó
AB 2439
Page 1
ASSEMBLY THIRD READING
AB
2439 (Nazarian)
As Amended May 31, 2016
Majority vote
------------------------------------------------------------------
|Committee |Votes|Ayes |Noes |
| | | | |
| | | | |
| | | | |
|----------------+-----+----------------------+--------------------|
|Health |14-1 |Wood, Maienschein, |Olsen |
| | |Bonilla, Burke, | |
| | |Campos, Chiu, | |
| | |Dababneh, Gomez, | |
| | | | |
| | | | |
| | |Roger Hernández, | |
| | |Nazarian, | |
| | |Ridley-Thomas, | |
| | |Rodriguez, Santiago, | |
| | |Waldron | |
| | | | |
|----------------+-----+----------------------+--------------------|
|Appropriations |14-6 |Gonzalez, Bloom, |Bigelow, Chang, |
| | |Bonilla, Bonta, |Gallagher, Jones, |
| | |Calderon, Daly, |Obernolte, Wagner |
| | |Eggman, Eduardo | |
| | |Garcia, Roger | |
| | |Hernández, Holden, | |
| | |Quirk, Santiago, | |
AB 2439
Page 2
| | |Weber, Wood | |
| | | | |
| | | | |
------------------------------------------------------------------
SUMMARY: Creates a pilot project to be administered by the
Department of Public Health (DPH), in order to assess and make
recommendations regarding the effectiveness of the routine
offering of a human immunodeficiency virus (HIV) test in the
emergency department (ED) of a hospital. Specifically, this
bill:
1)Requires DPH to select four hospitals that have EDs to
voluntarily participate in the pilot project as follows:
a) Two of the hospitals must be from large urban areas;
b) One hospital must be from a small urban or suburban
area;
c) One hospital must be from a rural area;
d) Each hospital in the pilot project must offer an HIV
test to any patient in the ED who has consented to the HIV
test. Specifies that the ED must comply with all existing
notice and counseling requirements, and that the ED may
comply with those requirements by either using ED or other
hospital personnel or engaging the services of an HIV
organization that has experience in prevention counseling
for persons at risk for HIV;
e) Specifies that a hospital in the pilot project must not
AB 2439
Page 3
offer a test to any person who is being treated for a
life-threatening emergency or who lacks the capacity to
consent to an HIV test;
f) Requires a hospital in the pilot project to offer HIV
tests to individuals between 15 and 65 years of age,
inclusive, pursuant to the United States Preventive
Services Task Force (USPSTF) recommendations;
g) Authorizes a hospital in the pilot project to charge a
patient for the cost of the HIV testing;
h) Requires a hospital in the pilot project to collect and
report data on the following topics to DPH:
i) The frequency of HIV test offers;
ii) The frequency of consent or nonconsent to an HIV
test and any reasons given by the patient for the consent
or nonconsent;
iii) The time taken to offer an HIV test and secure
consent from a patient and the time taken to provide
information and counseling;
iv) The aggregate HIV positivity rate;
v) The frequency with which patients agree information
and counseling and the reasons that patients give for
refusing counseling; and,
AB 2439
Page 4
vi) The frequency of patients leaving the ED without
receiving their test results.
2)Requires hospitals in the pilot project to provide information
to DPH regarding the hospitals practices and protocols for
implementing the offer of an HIV test; the required follow up
to the test; as well as an assessment of the effectiveness of
those practices and protocols.
3)Specifies that the pilot project must commence on March 1,
2017, and end on February 28, 2019.
4)Requires DPH, by July 1, 2019, to complete a report to the
Legislature on the finding of the four hospitals in the pilot
and make recommendations about routine HIV testing in hospital
EDs. Requires DPH to solicit input form a broad range of HIV
testing and hospital stakeholders when preparing the report.
5)Authorizes DPH to seek or use private funding to cover the
costs of administering the pilot project.
FISCAL EFFECT: According to the Assembly Appropriations
Committee:
1)Staff costs to DPH of $305,000 in fiscal year 2016-17,
$550,000 in 2017-18, and $275,000 in 2018-19 to implement and
manage the pilot project, collect data, and prepare a report
(General Fund (GF)or private funds).
2)Cost pressure to provide funding for hospitals to participate
AB 2439
Page 5
in this project. Although they can be reimbursed for HIV
testing, it is unclear whether hospitals would participate
without funding for enhanced tracking and data collection
efforts. A current Centers for Disease Control and Prevention
(CDC) grant provides $270,000 per year to each hospital
participating in a similar pilot project (GF or private
funds).
3)Identifying more individuals with HIV could increase testing
and treatment costs to Medi-Cal and the AIDS Drug Assistance
Program, and potentially reduce long-term costs by identifying
HIV infection and beginning treatment earlier before
significant medical complications arise, as well as by
potentially preventing additional transmission. The pilot
project is relatively small and thus any fiscal impact to the
state for additional treatment would be small. The net effect
on costs is unknown.
COMMENTS: According to the author, over the past three decades,
almost every imaginable location to provide routine HIV testing
has been employed to capture as many people as possible who may
have engaged in risk behaviors. The author contends we continue
to come up short, in large part because HIV testing is occurring
only sporadically in the ED, the last major health care
institution in California where HIV testing does not occur
routinely. The author states despite dramatic advances in
treatment options, there are more than 5,000 new infections in
California every year and 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 exposing uninfected
people to HIV, and that number jumps to 58% for young people
under the age of 24. The author continues, despite the many
successes, the failures of our testing protocols are most
pronounced among young people and people of color, noting that
the state's HIV demographics are trending younger, notably
increasing in those aged 20 to 29, and climbing infection rates
among Black and Latino Californians, especially Black women.
AB 2439
Page 6
The California Office of AIDS estimates that approximately
126,000 Californians are living with HIV, and of these, 23,000
or 18% are unaware of their HIV status. An estimated 6,000
Californians are newly diagnosed with HIV each year. Gay,
bisexual, and other men who have sex with men (MSM) continue to
be the risk group most heavily affected by HIV in California,
accounting for over 70% of all persons diagnosed with HIV in
2013.
Unlike national statistics, new HIV diagnoses among all MSM in
California decreased by over 13% (from 3,789 to 3,281) from 2005
to 2013 (versus a national increase of 6%). White MSM in
California account for this decline, with an almost 35% decrease
in new diagnoses (versus a national decrease of 18%). Both
Latino and Black MSM in California had a net zero change in new
HIV diagnoses from 2005 to 2013 (versus national increases of
24% and 22%, respectively). Only "other" race/ethnicities in
California that had an increase in new HIV diagnoses during this
period (an increase of 30% from 2005 to 2013, driven primarily
by a 73% increase among Asians). "Other" race/ethnicity
includes American Indian/Alaska Native, Asian, Native
Hawaiian/Pacific Islander, and multi-racial persons.
However, young MSM aged 13 to 24 years old in California had an
overall increase of 27% in new HIV diagnoses from 2005 to 2013
(from 536 in 2005 to 680 in 2013). This increase was driven by
young Hispanic MSM, whose numbers increased by 35% (from 246 to
333). Diagnoses among young Black MSM in California increased
by 16% (from 124 to 144) during this period. Among young white
MSM new diagnoses increased approximately 8% (from 130 to 140),
compared to 56% nationally. New HIV diagnoses among young MSM
of other race/ethnicities in California increased by an even
higher percentage (75%) from 2005 to 2013, but there are
relatively few cases in this group (36 in 2005 to 63 in 2013).
AB 2439
Page 7
In September 2006, the CDC released, "Revised Recommendations
for HIV Testing of Adults, Adolescents, and Pregnant Women in
Health-Care Settings." These recommendations advise routine HIV
screening of adults, adolescents, and pregnant women in health
care settings in the United States. The CDC also recommends
reducing barriers to HIV testing. In April 2013, the USPSTF
issued similar recommendations. According to these
recommendations, clinicians should routinely screen adolescents
and adults ages 15 to 65 years for HIV infection. Younger
adolescents and older adults who are at increased risk should
also be screened. USPSTF also recommends screening all pregnant
women for HIV, including those who present in labor whose HIV
status is unknown.
According to a Kaiser Family Foundation report, as of 2012, more
than half (54%) of U.S. adults, aged 18 to 64, reported ever
having been tested for HIV, including 22% who reported being
tested in the last year. The share of the public saying they
have been tested for HIV at some point increased between 1997
and 2004, but has remained fairly steady since then. Of those
U.S. adults, aged 18-64, who say they have never been tested for
HIV, nearly six in 10 (57%) say it is because they do not see
themselves as at risk. HIV testing varies by state, age, and
race/ethnicity, for example, Blacks and Latinos are
significantly more likely to report having been tested for HIV
than whites.
Hospitals in two of California's largest urban settings, the
Alameda County Medical Center (ACMC) and Los Angeles County +
University of Southern California Medical Center (LAC+USC) have
been successful in integrating routine HIV testing in their EDs,
although neither facility has offered HIV testing to every
patient receiving a blood draw as this bill would require. As
an early adopter of HIV testing in their ED, ACMC utilized
medical staff for the introduction and provision of HIV tests.
Over a three year demonstration project (2010-12), ACMC
AB 2439
Page 8
identified 52 new HIV cases from 45,210 HIV tests conducted with
a positivity yield of 0.1%. In 2005, LAC+USC utilized a rapid
test approach, embedding test counselors to introduce and
provide HIV tests, and identified 13 new cases of HIV among
1,713 patients tested yielding a positivity yield of 0.8%. In
addition, a regional hospital, Desert Regional Medical Center in
Palm Springs, has implemented HIV testing in its ED. In 2015,
it tested 810 patients of which 17 were HIV positive for a
positivity rate of 2%. These positivity yields meet the
benchmark of 0.1% determined by the CDC to demonstrate cost
effectiveness of HIV testing in healthcare settings.
The AIDS Healthcare Foundation (AHF) is the sponsor of this bill
and states despite dramatic advances in treatment options, there
are more than 5,000 new infections in California every year, and
everyday more than a dozen Californians are being infected with
HIV. AHF contends that while almost every imaginable location
that provides routine HIV testing has been employed to capture
as many people as possible who may have engaged in risk
behaviors, we continue to come up short in large part because
HIV testing is occurring only sporadically in hospital EDs, the
last major health care institution where HIV testing does not
occur routinely.
The California Chapter of the American College (Cal/ACEP)
opposes this bill stating that the pilot project requires every
patient in an ED to be offered an HIV test, whether they are
having their blood drawn already or not, and as a practical
matter, this means that a patient who is there for a broken
foot, stiches, a concussion, or any other medical condition that
does not require blood to be drawn, will have their blood drawn
as a purely public health screening measure. Cal/ACEP notes
that it is aware that the CDC has stated that hospitals with an
AIDS diagnosis rate greater than one per 1,000 discharges should
adopt a policy of offering HIV counseling and testing routinely
to patients aged 15 to 54 years, however if ED prophylactically
tested for all diseases with a 0.001% prevalence, life-saving
AB 2439
Page 9
care to acutely ill patients would come to a screeching halt.
Analysis Prepared by:
Lara Flynn / HEALTH / (916) 319-2097 FN:
0003258