BILL ANALYSIS Ó SENATE COMMITTEE ON HEALTH Senator Ed Hernandez, O.D., Chair BILL NO: AB 2439 --------------------------------------------------------------- |AUTHOR: |Nazarian | |---------------+-----------------------------------------------| |VERSION: |May 31, 2016 | --------------------------------------------------------------- --------------------------------------------------------------- |HEARING DATE: |June 29, 2016 | | | --------------------------------------------------------------- --------------------------------------------------------------- |CONSULTANT: |Melanie Moreno | --------------------------------------------------------------- SUBJECT : HIV testing 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 an HIV test in the emergency department (ED) of a hospital. Requires DPH to select four hospitals that have EDs to voluntarily participate in the pilot project, as specified. Existing law: 1)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. 2)Requires a medical provider, prior to ordering an HIV test to 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 is required to note that fact in the patient's medical file. These provisions do not apply when a person independently requests an HIV test from a medical care provider. 3)Requires the medical provider or other person administering the test, after the results of an HIV test have been received, to ensure that the patient receives timely information and counseling, as appropriate, to explain the results and the implications for the patient's health. If the patient tests positive for HIV infection, the medical provider or the person AB 2439 (Nazarian) Page 2 of ? who administers the test is required to inform the patient that there are numerous treatment options available and identify follow-up testing and care that may be recommended, including contact information for medical and psychological services. If the patient tests negative but is known to be at high risk for HIV infection, the medical provider or the person who administers the test is required to 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 is permitted offer prevention counseling or a referral to prevention counseling. This bill: 1)Creates a pilot project, to be administered by DPH, in order to assess and make recommendations regarding the effectiveness of the routine offering of an HIV test in the ED of a hospital. Requires DPH to select four hospitals that have EDs to voluntarily participate in the pilot project, as follows: a) Two of the hospitals from large urban areas; b) One hospital from a small urban or suburban area; and, c) One hospital from a rural area. 2)Requires each hospital in the pilot project to offer an HIV test to any patient in the ED who has consented to the HIV test. Requires the ED to comply with existing law related to HIV testing, and permits the ED to comply either by using hospital personnel or engaging the services of an HIV organization that has experience in prevention counseling for persons at risk for HIV. 3)Prohibits a hospital in the pilot project from offering 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. 4)Requires a hospital in the pilot project to offer HIV tests to individuals between 15 and 65 years of age pursuant to USPSTF recommendations. 5)Authorizes a hospital in the pilot project to charge a patient for the cost of the HIV testing. 6)Requires a hospital in the pilot project to be directed by DPH AB 2439 (Nazarian) Page 3 of ? to collect and report data on: a) The frequency of HIV test offers; b) The frequency of consent or non-consent to an HIV test and any reasons given by the patient for the consent or the non-consent; c) The time taken to offer an HIV test and secure consent from a patient and the time taken to provide information and counseling, as specified; d) The aggregate HIV positivity rate; e) The frequency with which patients agree to participate in a session to receive information and counseling pursuant to existing law related to HIV testing and the reasons that patients give for refusing to participate; and, f) The frequency of patients leaving the ED without receiving their test results. 7)Requires a hospital in the pilot project to provide information to DPH regarding its practices and protocols for implementing the offer of an HIV test and the required followup to the test, as well as an assessment of the effectiveness of those practices and protocols. 8)Commences the pilot project on March 1, 2017, and ends it on February 28, 2019. 9)Requires DPH, by July 1, 2019, to complete a report to the Legislature on the findings of the four hospitals in the pilot project and make recommendations about routine HIV testing in EDs, as specified. Requires DPH, in preparing the report to the Legislature, to solicit input from a broad range of HIV testing and hospital stakeholders. Makes this provision inoperative on July 1, 2023, as specified. 10)Permits 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). AB 2439 (Nazarian) Page 4 of ? 2)Cost pressure to provide funding for hospitals to participate 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. PRIOR VOTES : ----------------------------------------------------------------- |Assembly Floor: |54 - 24 | |------------------------------------+----------------------------| |Assembly Appropriations Committee: |14 - 6 | |------------------------------------+----------------------------| |Assembly Health Committee: |14 - 1 | | | | ----------------------------------------------------------------- COMMENTS : 1)Author's statement. According to the author, the National Association of State and Territorial AIDS Directors declared in its most recent report that "hospital emergency rooms continue to play a critical role in the successful expansion of HIV testing." Given that there are more than 5,000 new HIV infections in California every year, AB 2439 will bridge the gap in lack of HIV testing by requiring the four selected hospitals to offer an HIV test to patients that have been admitted via the emergency department. The emergency room trigger is key, as emergency rooms will continue to play a AB 2439 (Nazarian) Page 5 of ? critical role in delivering primary care services to many new enrollees and to those who remain uninsured. AB 2439 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 2439 (Nazarian) Page 6 of ? 4)Related legislation. AB 2640 (Gipson) would require a medical care provider or person administering a test for HIV to inform individuals who test negative for HIV infection, yet are at high risk for HIV infection, of the effectiveness and safety of all federal Food and Drug Administration approved methods that prevent or reduce the risk of contracting HIV, including pre-exposure prophylaxis and post-exposure prophylaxis, consistent with guidance of the CDC. AB 2640 is set to the heard in the Senate Health Committee on June 29, 2016. 5)Prior legislation. AB 521 (Nazarian of 2015) would have required a patient admitted as an inpatient to a hospital through the ED that had blood drawn after being admitted to the hospital, and who consented, to be offered an HIV test. AB 521 was vetoed by the Governor, stating in part: "?hospitals are not appropriately staffed nor are they the place to provide counseling, routine preventive screenings, or follow-up care for sensitive HIV testing. Limited resources would be better spent supporting outreach and education activities by existing providers which have the staff and training for HIV testing and follow-up care." 6)Support. 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. 7)Author's amendments. The author requests that the Committee approve the following amendments respond to concerns about the offer of an HIV test when an ED patient is in too much pain or distress to give consent or when a minor patient does not feel free to make a decision about consent because of the presence of a parent or guardian. a) On page 2, between lines 24 and 25, insert: (2) If an emergency department physician at a hospital in AB 2439 (Nazarian) Page 7 of ? the pilot project determines that a patient is in significant pain or distress, including psychological distress, the hospital shall not offer a HIV test to the patient. Once an emergency department physician determines that the patient has stabilized and is no longer in significant pain or distress, including psychological distress, the hospital shall offer a HIV test to the patient. b) On page 2, in line 28, after the period insert: In order to protect the confidentiality and privacy interests of minors, the hospital shall not offer HIV test to individuals 15 to 17 years of age, inclusive, in the presence of their parent or legal guardian. SUPPORT AND OPPOSITION : Support: AIDS Healthcare Foundation (sponsor) Beyond AIDS City of West Hollywood Oppose: None Received -- END --