BILL ANALYSIS Ó ----------------------------------------------------------------- |SENATE RULES COMMITTEE | AB 2439| |Office of Senate Floor Analyses | | |(916) 651-1520 Fax: (916) | | |327-4478 | | ----------------------------------------------------------------- THIRD READING Bill No: AB 2439 Author: Nazarian (D) Amended: 8/15/16 in Senate Vote: 21 SENATE HEALTH COMMITTEE: 7-0, 6/29/16 AYES: Hernandez, Nguyen, Hall, Mitchell, Monning, Pan, Roth NO VOTE RECORDED: Nielsen, Wolk SENATE APPROPRIATIONS COMMITTEE: 5-2, 8/11/16 AYES: Lara, Beall, Hill, McGuire, Mendoza NOES: Bates, Nielsen ASSEMBLY FLOOR: 54-24, 6/2/16 - See last page for vote SUBJECT: HIV testing SOURCE: AIDS Healthcare Foundation DIGEST: This bill 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. ANALYSIS: 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, AB 2439 Page 2 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 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: AB 2439 Page 3 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) Permits DPH to select fewer hospitals if an insufficient number of hospital express willingness to voluntarily participate. 3) 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. 4) 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. 5) Requires a hospital in the pilot project to offer HIV tests to individuals between 15 and 65 years of age pursuant to USPSTF recommendations. 6) Authorizes a hospital in the pilot project to charge a patient for the cost of the HIV testing. 7) Requires a hospital in the pilot project to be directed by DPH, in a form, manner, and timeframe determined by DPH, 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; AB 2439 Page 4 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. 8) 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 follow-up to the test, as well as an assessment of the effectiveness of those practices and protocols. 9) Commences the pilot project on March 1, 2017, and ends it on February 28, 2019. 10)Requires DPH, by December 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. 11)Requires this bill to be implemented only to the extent that DPH identifies available funding for its purposes. Permits DPH to seek or use private funding to cover the costs of administering the pilot project. Background According to a 2015 Centers for Disease Control and Prevention (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 AB 2439 Page 5 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 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. 1)HIV positive but unaware. According to the CDC, of the nearly 1.2 million people estimated to be living with HIV in the U.S., 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. Comments 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 AB 2439 Page 6 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 ED. The emergency room trigger is key, as emergency rooms will continue to play a 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. FISCAL EFFECT: Appropriation: No Fiscal Com.:YesLocal: No According to the Senate Appropriations Committee: 1)One-time costs of $305,000 in 2016-17 and $560,000 in 2017-18 for the DPH to oversee the pilot project (General Fund). 2)By requiring hospitals to offer additional HIV testing to patients, the bill will increase the number of tests provided and the number of previously undiagnosed individuals who will be diagnosed with HIV, typically leading to treatment. The number of additional tests provided and the number of previously undiagnosed cases of HIV discovered through those tests is subject to uncertainty. Based on information developed by the Office of Statewide Planning and Development, there are about 14 million ED patient encounters per year. If 10% of the encounters in participating hospitals lead to an HIV test and the population accepting the test has roughly the same rate of undiagnosed HIV as the overall state population, there would be about 10-20 newly diagnosed cases of HIV identified per year. This would result in the following state costs: a) About $150,000 per year for additional HIV testing (including follow up testing for positive test results) by the Medi-Cal program (General Fund and federal funds). b) About $200,000 per year to provide medical care Medi-Cal enrollees newly diagnosed with HIV (General Fund and federal funds). AB 2439 Page 7 c) About $50,000 per year to provide medical care to new AIDS Drug Assistance Program enrollees (federal funds and drug rebate funds). 3)Unknown long-term cost savings to Medi-Cal due to earlier medical intervention for HIV-positive Medi-Cal enrollees. To the extent that HIV-positive Medi-Cal enrollees are diagnosed earlier and begin treatment earlier, it is likely that the long-term health status of those individuals will improve and some of the health effects of HIV will be delayed or avoided. There are indications that untreated HIV causes long-term health impacts such as elevated risk of diabetes and heart disease, even before the effects of compromised immune system function associated with HIV infection become evident. Earlier diagnosis and treatment for HIV-positive individuals may to reduce long-term Medi-Cal expenditures for those individuals. However, to some unknown extent the improvement in health status and reduction in health care needs will be offset by longer lifespans, potentially offsetting cost savings. 4)Unknown cost savings due to reduced HIV infections in the state, including amongst Medi-Cal beneficiaries. There are academic findings that diagnosis of HIV significantly reduces the likelihood that an HIV positive individual will infect others. This is due both to a reduction in risky behavior by those aware of their HIV positive status and reductions in viral loads in the blood due to antiretroviral treatments. To the extent that the bill results in new diagnoses of HIV and that newly diagnosed individuals are able to access appropriate medical care, the bill is likely to prevent future HIV infections. SUPPORT: (Verified 8/12/16) AIDS Healthcare Foundation (source) Beyond AIDS City of West Hollywood OPPOSITION: (Verified8/12/16) None received AB 2439 Page 8 ARGUMENTS IN 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. ASSEMBLY FLOOR: 54-24, 6/2/16 AYES: Achadjian, Alejo, Atkins, Baker, Bloom, Bonilla, Bonta, Brown, Burke, Calderon, Campos, Chau, Chiu, Chu, Cooley, Cooper, Dababneh, Daly, Dodd, Eggman, Frazier, Cristina Garcia, Eduardo Garcia, Gipson, Gomez, Gonzalez, Hadley, Roger Hernández, Holden, Irwin, Jones-Sawyer, Levine, Linder, Lopez, Low, Maienschein, Mayes, McCarty, Mullin, Nazarian, O'Donnell, Quirk, Ridley-Thomas, Rodriguez, Salas, Santiago, Mark Stone, Thurmond, Ting, Waldron, Weber, Williams, Wood, Rendon NOES: Travis Allen, Arambula, Bigelow, Brough, Chang, Chávez, Dahle, Beth Gaines, Gallagher, Gatto, Gray, Grove, Harper, Jones, Kim, Lackey, Mathis, Melendez, Obernolte, Olsen, Patterson, Steinorth, Wagner, Wilk NO VOTE RECORDED: Gordon, Medina Prepared by: Melanie Moreno / HEALTH / (916) 651-4111 8/15/16 20:33:29 **** END ****