1. Meredith Carr, JD J. Stan Lehman, MPH David W. Purcell, JD, PhD Division of HIV/AIDS Prevention Centers 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

2. 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

3. 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

4. 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

5. DHAP’s General Methods for Public 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

6. 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

7. 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

8. 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

10. 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

12. 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])

14. 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

15. 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

16. For more information please contact Centers for Disease Control and Prevention 1600 Clifton Road NE, Atlanta, GA 30333 Telephone, 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348 E-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