BILL ANALYSIS Ó AB 2439 Page 1 CONCURRENCE IN SENATE AMENDMENTS AB 2439 (Nazarian) As Amended August 15, 2016 Majority vote -------------------------------------------------------------------- |ASSEMBLY: |54-24 |(June 2, 2016) |SENATE: |32-7 |(August 23, | | | | | | |2016) | | | | | | | | | | | | | | | -------------------------------------------------------------------- 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. AB 2439 Page 2 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: AB 2439 Page 3 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 AB 2439 Page 4 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 AB 2439 Page 5 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 AB 2439 Page 6 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 AB 2439 Page 7 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