Meredith Carr, JDJ. Stan Lehman, MPH

David W. Purcell, JD, PhD

Division of HIV/AIDS PreventionCenters for Disease Control and Prevention

July 25, 2012

Applying Public Health Law Research Methods to Address Legal Barriers

and Facilitators to Effective HIV Prevention Programs

2012 International AIDS Conference, Washington, D.C.

National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention

Centers for Disease Control and Prevention

The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the U.S. Centers for Disease Control and Prevention

Overview

The importance of state legal/policy environments for public health

CDC’s Division of HIV/AIDS Prevention’s (DHAP’s) Legal Assessment Project – Methods

Examples of applying PHLR methods to different legal/policy domains

Background: The Importance of State Policy Environments in the United

States

By the principle of “federalism,” the U.S. federal gov’t delegates important legal authority to the 50 states to develop statutes and regulations

State statutory and regulatory (legal) frameworks: are structural interventions that can be barriers or

facilitators to HIV prevention and care efforts have important public health implications can improve the effectiveness of HIV prevention and

care programs for individual states and the nation as a whole

Improving policy environments can be cost-effective and contribute to improving health equity

DHAP’s Legal Assessment Project

Goals: Assess the public health implications of state-level laws

and policies to help promote effective HIV prevention and care policy environments

Develop standardized public health law research (PHLR) methods and protocols that are consistent with scientific research methods

Build a consistent evidence base across multiple domains of HIV prevention and care to assist CDC and other agencies in developing national HIV policy recommendations

Focus on evaluating the text of the law as written, not on offering opinions on legal interpretations

DHAP’s General Methods forPublic Health Law Research (PHLR)

For each research question or domain, the team collects and analyzes state laws and policies for all 50 states and the District of Columbia (DC)

For each domain of interest, preliminary research also identifies existing legal analyses

Ongoing consultation with CDC’s Public Health Law Program and Temple University , Beasley School of Law

Alternative methods and types of data are considered when state-level legal data are unavailable or do not exist

General PHLR Methods (cont.)

Systematic search terms are developed and then applied to legal databases such as WestlawNext© The task relies on having a high-quality, searchable

legal database covering all jurisdictions

The legal text identified by the search is entered into an Access database and coded to answer relevant research questions using qualitative coding methods

Coded data can be translated into SAS datasets for additional quantitative analysis

Case Examples of Applying our General Methods for PHLR to Different

Legal/Policy Domains

Laboratory reporting of CD4 and viral load results to HIV surveillance programs

Consistency of HIV testing laws with CDC’s 2006 recommendations for routine screening in clinical settings

Medicaid reimbursement for routine HIV screening

Background and Methods: Laboratory Reporting of CD4 & Viral

Load

CD4 and viral load data are fundamental surveillance data needed to assess linkage to care, viral suppression and other HIV prevention and care outcomes

CDC recommends reporting all CD4 and all viral load values to state HIV surveillance programs (including undetectable results)

Primary data obtained from: State regulations rather than statutes Updates on regulatory changes may be reported by

grantees, due to lab reporting being a rapidly changing legal environment

Background and Methods: State HIV Testing Laws

Increased availability of HIV screening increases testing rates among populations at increased risk of HIV

CDC’s 2006 Testing Recommendations: HIV screening in health care settings for all persons aged 13 to 64 HIV screening laws were evaluated looking specifically at

the two parameters of simplifying the consent process and streamlining pre- and post-test counseling requirements

Data through 2011 was collected by the National HIV/AIDS Clinicians’ Consultation Center (NCCC) at UCSF and since then updated by CDC through June 2012

Background and Methods: State Medicaid Reimbursement for Routine

HIV Screening Medicaid is a system that pays for health care for

disadvantaged populations Reimbursement would increase HIV screening opportunities

In this federal program, states have the option to pay for HIV screening

Search of laws did not identify reimbursement information

An alternative approach was developed: Data collected by a survey of State AIDS directors (by

National Alliance of State and Territorial AIDS Directors [NASTAD])

Data Limitations and Challenges

Focus is on the state level, not local laws and ordinances

Legal text may not be available to answer all questions may need to collect additional data

Confounders- implementation, interpretation and enforcement of laws may be different than the legal text

Some domains are changing rapidly requiring resources for frequent updating

Conclusions & Next Steps

State statutory and regulatory frameworks play a key role in HIV prevention activities

Systematic PHLR uses a variety of data sources to assess state laws and policies and can be: Applicable internationally or for cross-country

comparisons Monitored over time to examine policy change

Next steps include: Combining results from analysis of our legal datasets

with surveillance and census data to examine associations between policy environment and public health outcomes

Updating existing domains and expanding to other legal domains

For more information please contact Centers for Disease Control and Prevention1600 Clifton Road NE, Atlanta, GA 30333Telephone, 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348E-mail: cdcinfo@cdc.gov Web: www.cdc.gov

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Thank you!

National Center for HIV/AIDS, Viral Hepatitis, STD & TB Prevention

Division of HIV/AIDS Prevention