BILL ANALYSIS Ó
AB 2640
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CONCURRENCE IN SENATE AMENDMENTS
AB
2640 (Gipson)
As Amended August 15, 2016
Majority vote
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|ASSEMBLY: |57-20 |(June 1, 2016) |SENATE: |26-11 |(August 18, |
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Original Committee Reference: HEALTH
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, and are
determined to be at high risk for HIV infection by the medical
provider or person administering the test, with information
about 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).
The Senate amendments delete the requirement that the
information be provided in writing and make other technical and
clarifying changes.
FISCAL EFFECT:
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1)Likely ongoing costs in the millions to low tens of millions
to provide PrEP and PEP to high-risk individuals enrolled in
Medi-Cal (General Fund and federal funds). Based on CDC
estimates for the number of individuals at high risk for HIV
infection, staff estimates that there are about 150,000
individuals in the state that would meet CDC guidelines for
using PrEP or PEP. For each 1% of that population that elects
to begin taking PrEP, the proportional cost to the Medi-Cal
program to cover the cost of providing PrEP would be about $4
million per year. (Costs for PEP would be considerable lower,
since it is only recommended for 28-day use, as opposed to
ongoing use for PrEP.)
2)Unknown long-term savings to Medi-Cal and the Aids Drug
Assistance Program due to lower HIV infection rates (General
Fund and federal funds). To the extent that the bill does
result in lower HIV infection rates, there would be cost
savings to the Medi-Cal and Aids Drug Assistance Programs.
However, there are some factors that limit the potential cost
savings from the bill. First, it is not known how effective
greater knowledge and use of PrEP and PEP are at the
population level in reducing HIV infection. There are
clinical studies that show a very dramatic decline in HIV
infections amongst users of PrEP. Whether those findings
would translate to the larger population not part of a
research study is unknown. Second, the annual cost to provide
PrEP is may not be substantially less than the current cost to
provide treatment to HIV positive Medi-Cal beneficiaries. The
cost that Medi-Cal would pay for PreP is not public
information. However, the New York State Department of Public
Health indicates that annual costs range from $8,000 to
$14,000 per year. Even assuming that Medi-Cal receives
significant discounts, the cost to provide PreP is likely to
be in the thousands per patient per year. On the other hand,
the current average annual cost of care for an HIV positive
Medi-Cal beneficiary is about $15,000 per year.
COMMENTS: According to the author, this bill seeks to reduce
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the spread of HIV and save the lives of individuals at high risk
of HIV exposure by providing them with information about
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
PrEP. In 2015, the California HIV/AIDS Research Program
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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 (lesbian, gay,
bisexual, transgender) 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.
Analysis Prepared by:
Lara Flynn / HEALTH / (916) 319-2097 FN:
0004124
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