BILL ANALYSIS Ó
AB 2439
Page 1
CONCURRENCE IN SENATE AMENDMENTS
AB
2439 (Nazarian)
As Amended August 15, 2016
Majority vote
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|ASSEMBLY: |54-24 |(June 2, 2016) |SENATE: |32-7 |(August 23, |
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Original Committee Reference: HEALTH
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.
The Senate amendments:
1)Specify that if an ED physician at a hospital in the pilot
determines that a patient is in significant pain or distress,
including psychological distress, the hospital will not offer
an HIV test to the patient, but that once an ED physician
determines that the patient has stabilized and is no longer in
significant pain or distress, the hospital will offer an HIV
test to the patient.
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2)Authorize DPH to select fewer hospitals to participate in the
pilot if an insufficient number of hospitals express
willingness to voluntarily participate.
3)Specify that data on the pilot collected by participating
hospitals will be in a form, manner, and timeframe determined
by DPH.
4)Change the due date of the report on the pilot required of DPH
from July 1, 2019, to December 1, 2019.
5)Specify that this bill will be implemented only to the extent
that DPH identifies available funding.
FISCAL EFFECT:
1)One-time costs of $305,000 in 2016-17 and $560,000 in 2017-18
for DPH to oversee the pilot project (General Fund (GF)).
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 emergency department 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:
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a) About $150,000 per year for additional HIV testing
(including follow up testing for positive test results) by
the Medi-Cal program (GF and federal funds).
b) About $200,000 per year to provide medical care Medi-Cal
enrollees newly diagnosed with HIV (GF and federal funds).
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
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appropriate medical care, the bill is likely to prevent future
HIV infections.
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.
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
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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).
In September 2006, the Centers for Disease Control and
Prevention (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 United
States Preventive Services Task Force (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.
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
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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
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
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tested for all diseases with a 0.001% prevalence, life-saving
care to acutely ill patients would come to a screeching halt.
Analysis Prepared by:
Lara Flynn / HEALTH / (916) 319-2097 FN:
0004123 0003258