PI Action alerts & updates ... 2007

New Strategies in the Fight Against HIV/AIDS:
An Advocacy Agenda for the 2007 Legislative Session

Developed by the California HIV Alliance (San Francisco AIDS Foundation, Project Inform, AIDS Project Los Angeles, LA Gay & Lesbian Center, Bienestar, AIDS Healthcare Foundation and AIDS Services Foundation of Orange County)

Introduction
The California HIV Alliance applauds the progress California has made since 1981 to control the HIV/AIDS epidemic. But despite an enormous investment of intellect and funding, progress in further controlling the epidemic appears to have stalled.

An estimated 25 percent of Californians who are HIV-positive do not know their HIV status. An estimated 20 percent of Californians who know they are HIV-positive are not receiving treatment for their HIV infection. Additionally, the number of Californians who are becoming newly infected with HIV remains constant at 6,700 to 9,000 people every year. Many of these issues disproportionately affect particular populations that have already suffered deeply from HIV/AIDS, including gay men, women and communities of color.

Through the following set of proposed budgetary and legislative initiatives, the Alliance seeks to establish a new set of strategies that can substantially impact the troubling set of indicators described above. These initiatives have four broad aims:

• To increase HIV screening among all Californians aged 13 to 64 and in certain high-risk groups;
• To address high rates of HIV infection in the state’s prisons;
• To ensure the continued strength of the state’s existing HIV prevention programs; and
• To ensure the continued strength of programs to treat low-income Californians who are HIV-positive in order to improve their health and prevent HIV transmission to others.

Budget Initiatives

1. Fully fund the AIDS Drug Assistance Program
In FY 2006-07, the AIDS Drug Assistance Program will provide medications to treat HIV infection and its related conditions for some 31,600 low-income Californians. The total cost of the program will be $296.4 million, of which $107.6 million will come from the state’s general fund.

Cost savings achieved by ADAP from efforts to assure that applicants use other health care coverage if they are eligible (Medicare and Medi-Cal in particular), combined with California’s leadership in negotiating low drug prices and manufacturer rebates, appear to mean that ADAP will not require an investment of additional general fund dollars in FY 2007-08. As a result, the Governor proposed no increase in funding for ADAP in his draft budget. Barring any new information suggesting that additional funds are needed by the program, the Alliance supports the Governor’s proposal.

2. Increase funding for the Therapeutic Monitoring Program—$4.7 million
Standards of care for HIV-infected people recommend quarterly tests to measure CD4 (T-cell) count and viral load, two important measures of immune system functioning. Individuals who have failed a regimen of HIV medications are also urged to receive a drug resistance test to determine which of the available anti-retroviral medications for HIV might help to reduce their infection. Additionally, it recently became standard of care to test people initiating HIV treatment for resistant strains of HIV in order to determine the optimal therapeutic strategy.

California’s Therapeutic Monitoring Program (TMP) provides vouchers to counties to permit low-income, HIV-positive individuals to obtain viral load and resistance tests. The program helps ADAP to be cost-effective by ensuring that the HIV medications it provides are having maximum benefit, .

In FY 2001-02, TMP was funded at $8 million. In FY 2002-03, it was reduced to $1 million and $7 million was transferred to ADAP. From FY 2003-04 to the present, TMP has been funded at $4 million. A program review established that, if the program was structured differently, it could need as much as $15 million per year to fully meet the needs of low-income individuals with HIV.

Based on the current structure of the program and the need for FY 2007-08, the Alliance is requesting an increase of $4.7 million annually in funding for the Therapeutic Monitoring Program.

3. Increase HIV testing—two programs totaling $4.5 million

a. Expand testing outreach to high-risk populations—$2.5 million

A specific set of strategies has been successful in increasing testing among high-risk individuals who have never been tested for HIV. First is the use of mobile vans that visit places frequented by high-risk individuals. Second is the use of fixed HIV testing sites in neighborhoods frequented by individuals at high-risk for HIV infection.

The Alliance is requesting an increase of $2.5 million annually to the state’s HIV Testing and Counseling budget. These funds will permit the Office of AIDS to issue a Request for Proposals to expand mobile HIV testing, the availability of neighborhood-based HIV testing, and other innovative strategies with demonstrated success in increasing testing among high-risk individuals.

b. Establish funding to permit emergency rooms in county hospitals to offer HIV testing to all patients - $2 million

Having never been tested for HIV, a substantial number of people present at emergency rooms with symptoms of advanced HIV infection or AIDS. For some, death follows rapidly as a result of the failure to receive earlier treatment. Because many individuals at high risk for HIV infection receive their only medical care in county-operated emergency medical settings, assuring that these patients are routinely offered an HIV test would help identify HIV-positive individuals earlier in the disease process, prolong their lives and save money.

A CDC-funded pilot project to offer rapid HIV tests to all patients in the emergency room at Alameda County’s Highland Hospital in 2006 identified 77 previously undiagnosed HIV-positive individuals among the 6,057 patients who consented to testing.

The Alliance is requesting an increase of $2 million annually to the HIV Testing & Counseling budget to allow the Office of AIDS to develop a program of HIV testing in emergency rooms of county operated hospitals.

4. Establish funding for a demonstration project to distribute condoms using an Office of AIDS website—$500,000
Condoms remain the most important tool to prevent sexually transmitted HIV infection, and assuring the availability of a free supply of these barriers in a wide variety of settings is essential. Based upon a successful program operated by the New York City Department of Health, the Alliance is proposing a $500,000 allocation allowing the Office of AIDS to create an internet-based condom distribution campaign. The program would permit health, social services agencies and businesses frequented by sexually active people at high risk for HIV infection to order condoms through an Office of AIDS website.

5. Fund the treatment of methamphetamine use among men who have sex with men—$2.5 million
The widespread use of methamphetamine among gay and other men who have sex with men (MSM) is contributing substantially to new HIV cases. Its use is also limiting the effectiveness of HIV treatment for many positive individuals and contributing to the spread of certain sexually transmitted diseases - particularly syphilis.

The Legislature and Governor responded to this problem with the appropriation of $10 million in the FY 2006-07 budget to fund meth prevention activities targeting MSM, women of child-bearing age and youth. The Department of Alcohol & Drug Programs has issued a Request for Proposals to expend those funds during the remainder of FY 2006-07. The Governor agreed to annualize that budget item in his FY 2007-08 budget proposal.

Programs that treat methamphetamine use among gay and other men who have sex with men report that they have waiting lists for their services. The Alliance is therefore requesting an appropriation of $2.5 million annually to expand methamphetamine treatment services for men who have sex with men.

Legislative Initiatives

1. Encourage routine HIV testing for all adult Californians by amending state laws governing consent for HIV testing
The Centers for Disease Control and Prevention estimates that approximately one quarter of all Americans with HIV do not know they are HIV-positive. Based on the CDC’s analysis, California’s Office of AIDS estimates that 30,000-40,000 Californians do not know that they are HIV-positive. These individuals are therefore not treating their HIV infection and may be unknowingly exposing others to the virus. To address this problem, the CDC has recommended routine HIV testing for all Americans aged 13 to 64.

Private healthcare providers assert that California’s current laws governing consent for HIV testing are sufficiently burdensome that many do not offer tests to their patients. Data also suggest that current consent requirements deter individuals from being tested. Many medical providers believe that, in the interest of expanding testing, current statute governing consent for HIV testing should be eliminated altogether. Other providers and community groups argue that extensive information should be provided to a prospective tester and that written informed consent should be obtained from each patient.

The Alliance believes in striking a balance between these competing views to make certain that a patient understands the HIV test and has a right to decline the test while also making HIV testing less time-consuming, less threatening and therefore more likely to take place. We support a bill to accomplish this change in the interest of increasing the number of individuals who know that they are HIV-positive, able to protect their health and avoid infecting others.

2. Require the offering of HIV testing to the state’s inmates and assure access to health care for those who test positive
Studies show that the prevalence of HIV in California prisons is nearly eight times that of the general population. A substantial number of inmates who are HIV-positive enter prison without knowing their HIV status. Despite the fact that it is illegal for them to have sex while incarcerated, sex does occur between inmates and, in some cases, HIV transmission. Many individuals who become infected in prison are subsequently released into communities and, because they have not been encouraged to take an HIV test, unknowingly transmit HIV to others.

Assemblyman Dymally has introduced AB 66. This bill would require the testing of all state inmates upon entering and leaving prison. The Alliance seeks to amend the bill to achieve several objectives. First, an existing set of rules in prisons that acts as a powerful disincentive for inmates to learn their HIV status must be eliminated. These rules limit visitation by family and spouses and make work, education and other programs that can reduce time served unavailable to HIV-positive inmates. Second, inmates should be offered a test upon entering and leaving prison and be informed of their right to decline to be tested. Third, every inmate who tests positive must have a care and treatment plan developed for them. Fourth, inmates who test positive for HIV should be encouraged to participate in a partner notification program on a voluntary basis. Finally, inmates must be connected with community-based HIV care, treatment and social services when they leave prison.

3. Permit the distribution of condoms in state prisons
Laws prohibiting sex between inmates will not prevent sex in prisons and the resulting transmission of HIV. Thus, it is inhumane and counter-productive not to make condoms available to the state’s prison inmates. Not only does the prohibition against condoms contribute to the spread of HIV inside and outside prison walls, it results in a preventable health care cost for the state.

In 2006, the Legislature passed AB 1667 (Koretz), which would have permitted non-profit organizations to distribute condoms in prisons. The bill was vetoed by Governor Schwarzenegger, who cited the existence of statute prohibiting sex between inmates as precluding condom distribution. The Alliance will reintroduce legislation making condoms available in state prisons and establishing that the possession of a condom is not a violation of the statutory prohibition against sex in prisons.

4. Eliminate state regulations on HIV rapid tests that discourage providers from screening patients
The introduction of HIV rapid testing has greatly enhanced the state’s ability to quickly and inexpensively test individuals for HIV infection. Business and Professions Code sections 1220 and 1244 provides for regulations providers must meet in order to test individuals for HIV infection – regulations the state laboratories implementing the regulations and the Office of AIDS agree create an unnecessary barrier to accessible HIV testing.

The Alliance is introducing a bill to amend the B&P Code to eliminate existing regulations on this subject; an approach that will take less time than going through the regulatory process.

5. Permit the use of state HIV prevention funding, generated by the general fund, to be used to purchase sterile syringes.
In 2006, Assemblyman John Laird introduced AB 2076 to permit local entities that receive HIV prevention funds from the Office of AIDS to purchase sterile syringes for authorized needle exchange programs. While state prevention funds can currently be used to pay for staffing and other expenses necessary to run a needle exchange program, programs in several jurisdictions have been interrupted because of their inability to purchase syringes with federal or state dollars. AB 2067 was held at the Governor’s desk.

Assemblyman Laird will reintroduce this legislation in 2007, and the Alliance urges the Legislature to approve it.