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