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AB 2640
Page 1
CONCURRENCE IN SENATE AMENDMENTS
AB 2640 (Gipson)
As Amended August 15, 2016
Majority vote
ASSEMBLY:
57-20
(June 1, 2016)
SENATE:
26-11
(August 18, 2016)
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:
1) Likely ongoing costs in the millions to low tens of millions to provide PrEP and PEP to highrisk 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 the spread of HIV and save the
lives of individuals at high risk of HIV exposure by providing them with information about
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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 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
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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