BILL ANALYSIS Ó AB 2640 Page 1 ASSEMBLY THIRD READING AB 2640 (Gipson) As Amended April 21, 2016 Majority vote ------------------------------------------------------------------ |Committee |Votes|Ayes |Noes | | | | | | | | | | | | | | | | |----------------+-----+----------------------+--------------------| |Health |12-5 |Wood, Bonilla, Burke, |Maienschein, | | | |Campos, Chiu, |Lackey, Olsen, | | | |Dababneh, Gomez, |Patterson, | | | | |Steinorth | | | | | | | | |Roger Hernández, | | | | |Nazarian, Rodriguez, | | | | |Santiago, Waldron | | | | | | | |----------------+-----+----------------------+--------------------| |Appropriations |14-6 |Gonzalez, Bloom, |Bigelow, Chang, | | | |Bonilla, Bonta, |Gallagher, Jones, | | | |Calderon, Daly, |Obernolte, Wagner | | | |Eggman, Eduardo | | | | |Garcia, Roger | | | | |Hernández, Holden, | | | | |Quirk, Santiago, | | | | |Weber, Wood | | | | | | | | | | | | AB 2640 Page 2 ------------------------------------------------------------------ SUMMARY: Requires a medical care provider or person administering a test for human immunodeficiency virus (HIV) to provide patients who test negative for HIV infection, yet are at high risk for HIV infection, with written information about the effectiveness and safety of all methods that prevent or reduce the risk of contracting HIV, including, but not limited to, pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP), consistent with guidance of the federal Centers for Disease Control and Prevention (CDC). FISCAL EFFECT: According to the Assembly Appropriations Committee, to the extent this bill raises awareness of drug therapy for people at high risk for HIV, this bill could potentially increase demand for and utilization of drug treatment for HIV prevention, particularly PrEP. According to the New York State Department of Health, Truvada, the drug used in PrEP therapy, costs between $8,000 and $14,000 per year. Medi-Cal prices for the drug are unknown, but even assuming significant discounts are available, costs to Medi-Cal could be in the millions annually if even a few hundreds more people a year take the medication (General Fund/federal). To the extent increased utilization with PrEP among high-risk populations reduces the number of HIV infections, there would be offsetting cost savings for less HIV/AIDS treatment in Medi-Cal and the AIDS Drug Assistance Program. Costs to the California Department of Public Health to produce updated written material, and to modify HIV counselor training, are minor and absorbable. COMMENTS: According to the author, this bill seeks to reduce the spread of HIV and save the lives of individuals at high risk of HIV exposure by providing them with information about AB 2640 Page 3 preventive medications during HIV post-test counseling. The author notes that in 2013, California was second among the 50 states in the number of new HIV diagnoses, with approximately 5,000 new HIV diagnoses, and a 2015 survey of individuals at risk for HIV by the California HIV/AIDS Research Program found that only one in 10 respondents had ever used PrEP. The author concludes, considering the high volume of new HIV infections being diagnosed in the state of California and the low awareness of these medications, it is critical that those being tested are aware of PEP and PrEP medications. Treatment as Prevention (TasP), PrEP, and PEP. In TasP, people living with HIV/AIDS use anti-retroviral (ARV) medications to reduce their viral load (the amount of HIV in the body) to undetectable levels. With an undetectable viral load, the amount of HIV in the body is so small it greatly reduces the likelihood of passing the virus to another person. Strict adherence to TasP reduces the likelihood of transmission by up to 96%. PrEP is a new intervention that uses an established ARV medication, Truvada to protect at-risk HIV-negative individuals from HIV infection. PrEP is different from PEP; the medication is taken before, not after possible exposure. Daily PrEP use can lower the risk of getting HIV from sex by more than 90% and from injection drug use by more than 70%. Missing doses reduces PrEP effectiveness. Truvada is currently the only FDA drug approved for HIV PrEP. PEP uses ARV medications to prevent HIV from replicating and spreading through the body after an exposure to the virus. PEP is a short-term (28-day) intervention and must be started within three days of an exposure - sooner, if possible - to be effective. PEP was originally developed for occupational exposures, such as needle-sticks in hospitals, but is also effective for sexual exposures. In 2015, the CDC estimated that one in four sexually active gay and bisexual men, one in five people who inject drugs, and one in 200 sexually active heterosexual adults meet the criteria for AB 2640 Page 4 PrEP. In 2015, the California HIV/AIDS Research Program conducted a survey of 602 young gay and bisexual men and found that only one in 10 had ever taken PrEP. Although awareness of the intervention was high among those who had never taken PrEP, awareness was significantly lower among Black and Latino respondents compared to white respondents. In addition, the large majority of respondents indicated they had never talked to their doctor or healthcare provider about PrEP. In its November 24, 2015 Morbidity and Mortality Weekly Report, the CDC estimated that 1.2 million Americans could benefit from PrEP, including 492,000 men who have sex with men, 115,000 injection drug users, and 624,000 heterosexuals. The report concludes that clinical organizations, health departments, and community-based organizations should raise awareness of PrEP among persons with substantial risk for acquiring HIV infection and their health care providers. AIDS Project Los Angeles and the Los Angeles LGBT Center are the cosponsors of this bill and they state that awareness and use of PrEP and PEP among Californians at risk for HIV remain extremely low. They conclude it remains vital to ensure that all individuals at risk for HIV receive accurate information about PrEP and PEP, particularly highly-impacted communities of color. The AIDS Healthcare Foundation (AHF) states in opposition that HIV screening is intended to mirror other screening tests, which require simple consent only and which do not burden the process with additional activities that may or may not be necessary. AHF asserts that its experience as the largest private tester in the state is that the more time and demands placed on the person it is encouraging to be tested, the more likely the person is to decline. The California Medical Association (CMA) is opposed to this bill stating, increased awareness of preventative treatment options for HIV should be a public health goal, however, it is AB 2640 Page 5 concerned that the increased medical resources required to accomplish the goal of this bill are not worth the benefit of the mandate. CMA notes that many preventative treatment options are not appropriate for every patient, and this bill would require a physician to inform the patient of a treatment option the physician might actually recommend against. Analysis Prepared by: Lara Flynn / HEALTH / (916) 319-2097 FN: 0003267