BILL ANALYSIS                                                                                                                                                                                                    Ó



          SENATE COMMITTEE ON HEALTH
                          Senator Ed Hernandez, O.D., Chair

          BILL NO:                    AB 2439             
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          |AUTHOR:        |Nazarian                                       |
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          |VERSION:       |May 31, 2016                                   |
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          |HEARING DATE:  |June 29, 2016  |               |               |
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          |CONSULTANT:    |Melanie Moreno                                 |
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           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  







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            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  :  
          
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          |Assembly Floor:                     |54 - 24                     |
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          |Assembly Appropriations Committee:  |14 - 6                      |
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          |Assembly Health Committee:          |14 - 1                      |
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          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. 








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          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
          
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