Federal Register, Volume 74 Issue 210 (Monday, November 2, 2009)

[Federal Register Volume 74, Number 210 (Monday, November 2, 2009)]
[Rules and Regulations]
[Pages 56547-56562]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: E9-26337]

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Disease Control and Prevention

42 CFR Part 34

[Docket No. CDC-2009-0003]
RIN 0920-AA26

Medical Examination of Aliens--Removal of Human Immunodeficiency
Virus (HIV) Infection From Definition of Communicable Disease of Public
Health Significance

AGENCY: Centers for Disease Control and Prevention (CDC), U.S.
Department of Health and Human Services (HHS)

ACTION: Final rule.

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SUMMARY: Through this final rule, the Centers for Disease Control and
Prevention (CDC), within the U.S. Department of Health and Human
Services (HHS), is amending its regulations to remove ``Human
Immunodeficiency Virus (HIV) infection'' from the definition of
communicable disease of public health significance and remove
references to ``HIV'' from the scope of examinations for aliens.
Prior to this final rule, aliens with HIV infection were considered
to have a communicable disease of public health significance and were
thus inadmissible to the United States per the Immigration and
Nationality Act (INA). While HIV infection is a serious health
condition, it is not a communicable disease that is a significant
public health risk for introduction, transmission, and spread to the
U.S. population through casual contact. As a result of this final rule,
aliens will no longer be inadmissible into the United States based
solely on the ground they are infected with HIV, and they will not be
required to undergo HIV testing as part of the required medical
examination for U.S. immigration.

DATES: This final rule is effective January 4, 2010.

FOR FURTHER INFORMATION CONTACT: Stacy M. Howard, Division of Global
Migration and Quarantine, Centers for Disease Control and Prevention,
U.S. Department of Health and Human Services, 1600 Clifton Road, NE.,
MS E-03, Atlanta, Georgia 30333; telephone 404-498-1600.

SUPPLEMENTARY INFORMATION: The preamble to this final rule is organized
as follows:

I. Legal Authority
II. Background
A. Medical Examination and Inadmissibility
B. Legislative and Regulatory History
C. Classes of Immigrants for Whom the Regulation Applies
D. Global Context
III. Summary of NPRM
IV. Relation of this Final Rule to the July 2, 2009, Notice of
Proposed Rulemaking
V. Overview of Public Comments
A. Comments on Removing HIV Infection From the Definition of
Communicable Disease of Public Health Significance
B. Comments on Removing HIV Testing From the Scope of
Examinations
C. Comments on the Economic Impact Analysis (EIA)
1. General Comments on the Cost Analysis
2. Comments on a Technical Review of the EIA
D. Comments on Technical Correction
VI. Conclusions and the Final Rule
VII. Required Regulatory Analyses Under Executive Order 12866
A. Objectives and Basis for the Action
B. Alternatives
C. Baseline and Incremental Analysis
D. Defining the Population Affected
E. Analysis of Impacts
1. Potential Benefits
2. Impact on Health Care Expenditures
3. Comparison With Congressional Budget Office Analysis
4. Potential Fiscal Impacts
5. Onward Transmission
F. Summary of Impacts
G. Literature Cited
VIII. Final Regulatory Flexibility Analysis
IX. Other Administrative Requirements
A. The Unfunded Mandates Reform Act
B. Executive Order 13045: Protection of Children From
Environmental Health and Safety Risks
C. Paperwork Reduction Act of 1995
D. Environmental Assessment
E. Executive Order 13175: Consultation and Coordination With
Indian Tribal Governments

[[Page 56548]]

F. Executive Order 12630: Governmental Actions and Interference
With Constitutionally Protected Property Rights
G. Executive Order 13132: Federalism
H. Executive Order 13211: Energy Effects
I. National Technology Transfer and Advancement Act
J. Assessment of Federal Regulations and Policies on Families
K. Executive Order 12988: Civil Justice Reform
L. Plain Language in Government Writing

I. Legal Authority

HHS/CDC is promulgating this rule under the authority of 42 U.S.C.
252 and 8 U.S.C. 1182 and 1222.

II. Background

A. Medical Examination and Inadmissibility

Under section 212(a)(1) of the INA (8 U.S.C. 1182(a)(1)), any alien
who is determined to have a communicable disease of public health
significance is inadmissible to the United States. As a result of this
statute, aliens outside the United States who have a communicable
disease of public health significance are ineligible to receive a visa
for admission into the United States, absent the grant of a waiver on
the ground of inadmissibility. The grounds of inadmissibility also
apply to most aliens who reside in the United States and are seeking
adjustment of their status to that of a lawful permanent resident.
The Secretary of Health and Human Services (HHS) is authorized to
promulgate regulations establishing the requirements for the medical
examination of aliens by sections 212(a)(1) and 232 of the Immigration
and Nationality Act (INA), and section 325 of the Public Health Service
Act (42 U.S.C. 252). The regulations, administered by HHS/CDC, are
promulgated at 42 CFR part 34.
HHS/CDC issues Technical Instructions, that provide the technical
consultation and guidance to panel physicians and civil surgeons who
conduct the medical examinations of aliens. Panel physicians,
designated by the U.S. Department of State (DoS) consular officers,
perform medical examinations on those refugees and/or persons living
outside the United States who are seeking to immigrate to the United
States. Civil surgeons, designated by the U.S. Citizenship and
Immigration Services within the U.S. Department of Homeland Security
(DHS), perform medical examinations for aliens who are already present
in the United States and are seeking adjustment of status. The CDC
Technical Instructions for Medical Examination of Aliens, including the
most current updates, that panel physicians and civil surgeons must
follow in accordance with these regulations, are available to the
public on the CDC Web site, located at the following Internet address:
http://www.cdc.gov/ncidod/dq/technica.htm.

B. Legislative and Regulatory History

Beginning in 1952, the language of the INA mandated that aliens
``who are afflicted with any dangerous contagious disease'' are
ineligible to receive a visa and therefore are excluded from admission
into the United States. In April 1986, prior to the recent developments
in medicine and epidemiologic principles concerning HIV infection, HHS
published a proposal in the Federal Register to include acquired
immunodeficiency syndrome (AIDS) as a dangerous contagious disease. See
51 FR 15354 (April 23, 1986). In June 1987, HHS published a final rule
adopting this proposal. See 52 FR 21532 (June 8, 1987). Also during
this time, HHS separately published a proposed rule to substitute HIV
infection for AIDS on the list of dangerous contagious diseases. See 52
FR 21607 (June 8, 1987). While this proposed rule was pending public
comment, Congress added HIV infection to the list of dangerous
contagious diseases. Pub. L. 100-71, section 518, 101 Stat. 475 (July
11, 1987). In response to the congressional mandate, HHS issued final
regulations to that effect in August of that year. See 52 FR 32540
(August 28, 1987). Accordingly and immediately, aliens infected with
HIV became ineligible to receive visas and were excluded from admission
into the United States. See INA section 212(a)(6), 8 U.S.C.
1182(a)(6)(1988).
In 1990, Congress amended the INA by revising the classes of
excludable aliens to provide that an alien who is determined (in
accordance with regulation prescribed by the Secretary of Health and
Human Services) to have a communicable disease of public health
significance is excludable from the United States. Immigration Act of
1990, Public Law 101-649, section 601, 104 Stat. 4978 January 23, 1990;
INA section 212(a)(1)(A)(i), 8 U.S.C. 1182(a)(1)(A)(i) (effective June
1, 1991). HHS/CDC subsequently published a proposed rule that would
have removed from the list all diseases, including HIV infection,
except for infectious tuberculosis. See 56 FR 2484 (January 23, 1991).
Based on public comments received on this proposal, and after
reconsideration of the issues, HHS published an interim final rule
retaining all diseases on the list, including HIV infection, and
committed its initial proposal for further study. See 56 FR 25000 (May
31, 1991). Congress subsequently amended INA section 212(a)(1) to
specify that ``infection with the etiologic agent for acquired immune
deficiency syndrome'' is a communicable disease of public health
significance, thereby making explicit in the INA that aliens with HIV
are ineligible for admission into the United States. National
Institutes of Health Revitalization Act of 1993, Public Law 103-43,
section 2007, 107 Stat. 122 (June 10, 1993).
In summer 2008, Congress amended the INA by striking ``which shall
include infection with the etiologic agent for acquired immune
deficiency syndrome,'' thereby leaving to the Secretary of HHS the
discretion for determining whether HIV infection should remain in the
definition of communicable disease of public health significance
provided for in 42 CFR 34.2(b). [Tom Lantos and Henry Hyde United
States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria
Reauthorization Act of 2008, Pub. L. 110-293, section 305, 122 Stat.
2963 (July 30, 2008)].
In a separate action on October 6, 2008, HHS/CDC published an
Interim Final Rule (IFR) announcing a revised definition of
communicable disease of public health significance and revised scope of
the medical examination in 42 CFR part 34. This IFR addressed concerns
regarding emerging and reemerging diseases in immigrant and refugee
populations who are bound for the United States. See 73 FR 58047 and 73
FR 62210. With the revision to 42 CFR Part 34, the definition of
communicable disease of public health significance was modified to
include two disease categories: (1) Quarantinable diseases designated
by Presidential Executive Order; and (2) a communicable disease that
may pose a public health emergency of international concern in
accordance with the International Health Regulations of 2005, provided
the disease meets specified criteria. Specific illnesses remaining as a
communicable disease of public health significance were active
tuberculosis, infectious syphilis, gonorrhea, infectious leprosy,
chancroid, lymphogranuloma venereum, granuloma inguinale, and HIV
infection.
In response to the 2008 amendment to the INA, on July 2, 2009, HHS/
CDC published a Notice of Proposed Rule Making (NPRM), which proposed
two regulatory changes: (1) The removal of HIV infection from the
definition of communicable disease of public health significance; and
(2) removal of

[[Page 56549]]

references to serologic testing for HIV from the scope of examinations.

C. Classes of Immigrants for Whom the Regulation Applies

The provisions in 42 CFR part 34 apply to the medical examination
of (1) aliens outside the United States who are applying for a visa at
an embassy or consulate of the United States; (2) aliens arriving in
the United States; and (3) aliens required by the U.S. Department of
Homeland Security (DHS) to have a medical examination in connection
with determination of their admissibility into the United States; and
(4) aliens who apply for adjustment of their immigration status to that
of lawful permanent resident.
While 42 CFR part 34 can apply to individuals who wish to come to
the United States on a temporary basis, such as leisure or business
travelers, a medical examination is not routinely required as a
condition for issuance of non-immigrant visas or entry into the United
States.
Aliens who are already in the United States may apply to adjust to
permanent resident status pursuant to statutorily-eligible adjustment
categories. See INA Sec. 245; 8 U.S.C. 1255. Refugees and aslyees may
also apply to adjust to permanent resident status from inside the
United States. See INA Sec. 209; 8 U.S.C. 1159.
An alien seeking permanent residence, whether through an immigrant
visa or asylee status, or through an adjustment of status must undergo
a medical examination to determine whether the alien is inadmissible on
medical grounds. Aliens seeking admission as refugees also undergo
medical examinations overseas. Overseas examinations are conducted by
panel physicians designated by the Department of State. Applicants for
adjustment of status to lawful permanent resident are required to have
a medical examination conducted by a civil surgeon designated by U.S.
Citizenship and Immigration Services within DHS.

D. Global Context

In 2004, the Joint United Nations Programme on HIV/AIDS (UNAIDS)
and the International Organization for Migration (IOM) issued the
``UNAIDS/IOM Statement on HIV/AIDS-related travel restrictions'' that
provides guidance to governments in regard to addressing the public
health, economic, and human rights concerns involved in HIV-related
travel restrictions. This document concludes that HIV-related travel
restrictions have no public health justification.

III. Summary of NPRM

On July 2, 2009, HHS/CDC published a notice of proposed rulemaking
(NPRM) to remove HIV infection from the definition of communicable
disease of public health significance, as defined in 42 CFR 34.2(b) and
from the scope of examinations in 42 CFR 34.3. See 74 FR 31798.

Section 34.2(b) Communicable Diseases of Public Health Significance

Until this final rule, human immunodeficiency virus (HIV) infection
was among those diseases listed in the definition of communicable
disease of public health significance, as defined in 42 CFR part
34.2(b). As described in the ``Legislative and Regulatory History''
section above, Congress amended the INA by striking ``which shall
include infection with the etiologic agent for acquired immune
deficiency syndrome,'' thereby leaving to the Secretary of HHS the
discretion for determining whether HIV infection should remain in the
definition of communicable disease of public health significance
provided for in 42 CFR 34.2(b). In consideration of scientific
evidence, including epidemiologic principles and current medical
knowledge regarding the mode of HIV transmission, HHS/CDC proposed to
remove HIV infection from the definition of communicable disease of
public health significance.

Section 34.3 Scope of Examinations

HHS/CDC also proposed to remove all references to serologic testing
for HIV infection in 42 CFR 34.3, which is entitled ``Scope of
examinations.'' This section applies to those aliens who are required
to undergo a medical examination for U.S. immigration purposes. The
scope of examinations outlines those matters that relate to the
inadmissible health-related conditions. This section provides specific
screening and testing requirements for those diseases that meet the
definition of communicable disease of public health significance and
directly relates to the diseases listed in Section 34.2(b) of 42 CFR
part 34. It does not provide specific testing requirements for other
health-related conditions that are not included in the current
definition of communicable disease of public health significance.
Therefore, HHS/CDC proposed to remove the specific testing
requirements for HIV infection in 42 CFR 34.3.

IV. Relation of This Final Rule to the July 2, 2009, Notice of Proposed
Rulemaking

Through this final rule, HHS/CDC is now removing HIV infection from
the definition of communicable disease of public health significance
and from the scope of examinations. HHS/CDC received over 20,000 public
comments on the NPRM, with the vast majority of commenters in support
of the proposed changes, as written. HHS/CDC's evaluation of the
comments did not lead to changes between the NPRM and this final rule.
While HIV infection is a serious health condition, scientific evidence
shows that it does not represent a communicable disease that is a
significant risk for introduction, transmission, and spread to the
United States population through casual contact. An arriving alien with
HIV infection--or one adjusting status to that of a legal permanent
resident--does not pose a public health risk to the general population
through casual contact.
Beginning on the effective date of this final rule, HIV infection
will no longer be an inadmissible condition, and HIV testing will no
longer be required, for those aliens who are required to undergo a
medical examination for U.S. immigration purposes.
The specific illnesses that are now listed in the definition of
communicable disease of public health significance are: Active
tuberculosis, infectious syphilis, gonorrhea, infectious leprosy,
chancroid, lymphogranuloma venereum, and granuloma inguinale. The
definition of communicable disease of public health significance also
consists of (1) quarantinable diseases designated by Presidential
Executive Order (E.O. 13295 as amended), and (2) communicable diseases
that could pose a public health emergency of international concern, in
accordance with the revised International Health Regulations of 2005,
provided the disease meets specified criteria.
As a result of this final rule, HHS/CDC has also revised the
Technical Instructions provided to panel physicians and civil surgeons
to reflect the removal of the HIV testing requirement. The revised
Technical Instructions will be immediately available to the public on
the HHS/CDC Division of Global Migration and Quarantine Web site,
located at the following Internet address: http://www.cdc.gov/ncidod/dq/technica.htm.
HHS/CDC will continue to work with DoS and DHS to ensure that panel
physicians and civil surgeons are aware of the revision to the
Technical Instructions. DHS and DoS will

[[Page 56550]]

determine the process for those applicants with HIV infection who have
current applications pending.

V. Overview of Public Comments

The public comment period for the NPRM lasted for forty-five (45)
days and ended on August 17, 2009. HHS/CDC received approximately
20,100 comments; of these, approximately 18,500 were largely similar
``form'' letters in favor of the proposed rule and also several
``form'' letters against the proposed rule. Comments were submitted by
individuals; advocacy organizations; international and national public
health agencies; immigration organizations; State and local health
departments; medical associations; international, national and local
AIDS organizations; corporate entities; various human rights; and other
organizations from across the globe. Some comments were the
collaborative effort of multiple groups. The comments will be
permanently located in the docket for this final rule and maintained by
HHS/CDC.
The sections below summarize and discuss the comments in detail:
Comments on removing HIV infection from the definition of communicable
disease of public health significance; comments on removing HIV testing
from the scope of examinations; comments on the Economic Impact
Analysis (EIA); and comments on technical correction. Data on the
numbers of comments received in support of and opposed to the rule are
provided below for informational purposes. However, these data are not
the determinative factor in guiding public policy or in making these
policy changes.

A. Comments on Removing HIV Infection From the Definition of
Communicable Disease of Public Health Significance

Most commenters supported CDC's public health assessment that HIV
infection should be removed from the definition of communicable disease
of public health significance as defined in 42 CFR 34.2(b)
(approximately 19,500 comments were received in support of CDC's
preliminary determination).
Many commenters stated that the practice of excluding HIV-infected
visitors and immigrants from the United States has no medical or public
health rationale. Most of these individuals and organizations supported
the language of the NPRM stating that the scientific evidence shows
that HIV infection is not a risk to the general population through
casual contact. Other comments submitted by individuals supporting
equal rights and HIV advocacy groups urged HHS/CDC to adopt the NPRM
verbatim as a final rule that removes HIV infection from the definition
of communicable disease of public health significance as defined in 42
CFR 34.2(b). In response, HHS/CDC has adopted the revisions to 42 CFR
34.2(b), as proposed. HHS/CDC has taken this action because based on
scientific evidence, HIV infection is not a threat to the general
population through casual contact and is no longer considered a
significant public health risk given advances in public health
practices and interventions for prevention and control.
A number of commenters supported the proposed rule for humanitarian
reasons, stating that the former regulation (a) stigmatizes and
discriminates against HIV-infected people, which include battered women
and children; the lesbian, gay, bisexual and transgender (LGBT)
community; or other vulnerable or already stigmatized populations; (b)
separates loved ones; (c) denies U.S. businesses and research
institutions access to talented workers; (d) bars students and tourists
from accessing opportunities and supporting our economy; and/or (e)
violates human rights by denying or interfering with the rights to
life, freedom of movement, privacy, liberty and work. While HHS/CDC
acknowledges these assertions, its mission is to protect public health
and base decisions upon solid scientific and medical grounds.
Therefore, there is no public health benefit for retaining this
government-imposed barrier.
Several organizations and individuals noted that preventing HIV-
infected travelers and/or immigrants from entering the United States is
also counter to the nation's longstanding leadership in fighting the
HIV/AIDS epidemic internationally. These commenters noted that no
international conference on HIV/AIDS has been held in the United States
since 1990 because of the former regulations. In response, HHS/CDC
notes that with this final rule, the United States will no longer be
included among the other countries that maintain entry restrictions for
HIV-infected individuals.
Many commenters suggested that the former regulations undermine
public health efforts, including the fight against HIV/AIDS, by keeping
HIV-infected researchers, advocates and experts from entering the
country and by preventing HIV-infected immigrants from taking their
medications in an effort to conceal their status from U.S. immigration
authorities. Some commenters indicated that effective treatment of HIV
infection requires a continuous antiviral regimen, and that
interrupting antiviral medication can result in difficulty treating the
virus as well as higher viral loads, which is also the most important
factor in transmissibility. In response, HHS/CDC acknowledges these
humanitarian and medical considerations. This final rule, based on
solid scientific and public health practices, removes HIV as a
condition barring entry into the United States.
A number of commenters did not support CDC's assessment that HIV
infection should be removed from the definition of communicable disease
of public health significance as defined in 42 CFR 34.2(b) (almost 600
comments). Many commenters who opposed the removal of HIV infection
from the definition of communicable disease of public health
significance cite financial concerns. They suggested that neither State
health departments, Federal government, nor individuals should have to
bear a significant financial burden to pay costs associated with
treating HIV conditions in immigrants. In addition, many submissions
pointed to the state of the economy and the recent debate over the
strength of the health care system as a reason not to admit HIV-
infected persons. Some commenters indicated that proof of ability to
pay for health care should be required for HIV-infected immigrants,
noting that HIV is a chronic, life-long infection, which is costly to
monitor and even more costly to effectively treat.
CDC acknowledges these concerns, including those related to the
potential financial burden that may result from this regulatory change.
However, these reasons are not part of the scientific criteria used in
determining whether HIV infection should be included as a defined
communicable disease of public health significance and as a basis for
admission to the United States. An individual infected with HIV will
not pose a significant risk to the general U.S. population since HIV
infection already exists as an endemic disease. Data have shown that
decrease in transmission rates of HIV is directly correlated with
national prevention efforts. CDC has and will continue to work on a
number of fronts to reduce the impact of HIV across the nation by
enhancing access to available prevention programs. These program
activities include expanding HIV testing to increase knowledge of HIV
status, improving surveillance to identify the leading edge of the
epidemic, and exploring innovative and promising new prevention
approaches. Communities and public health partners are working to
tailor prevention efforts to meet local needs, mobilize

[[Page 56551]]

communities, and expand the reach of HIV prevention.
Some commenters noted that changing the regulation at this current
time is ill advised, and several of the commenters opposed to the
proposed rule requested that the waiver remain a requirement for entry
into the United States. HHS/CDC acknowledges these comments, but notes
that the Part 34 regulations do not address the criteria for a waiver
of inadmissibility under Section 212 of the INA.
A few commenters asked why the U.S. government would put even one
person at risk of contracting HIV from an immigrant. In response, as
stated previously, scientific evidence confirms that HIV infection is
not transmitted in casual settings. An arriving alien with HIV
infection--or one adjusting status to that of a legal permanent
resident--does not pose a public health risk to the general population
through casual contact.
A few of these commenters, who did not support the removal of HIV
infection as a condition of inadmissibility, expressed concerns that
HIV infection should remain a communicable disease of public health
significance or be accepted as a disease of ``public health
significance,'' and cited morbidity and mortality rates of HIV
infection domestically and internationally. HHS/CDC acknowledges that
HIV infection is a serious illness and a major public health concern
both domestically and internationally. However, HHS/CDC notes that the
purpose of the NPRM was to determine whether HIV infection should
remain as a disease that bans entry to the United States for
immigration purposes. HHS/CDC, through this final rule, notes that HIV
infection will no longer be included in the definition of communicable
disease of public health significance, because scientific evidence
suggests that it is not transmitted through casual contact.
Other reasons cited by commenters opposing the rule change include
various comments such as: (a) HIV-infected persons should be allowed in
for tourism but not for permanent relocation; (b) allowing HIV-infected
immigrants into the country would allow new strains of HIV to circulate
in the United States; (c) reporting requirements for HIV infection seem
to indicate that HIV is a disease of public health significance; and
(d) removing HIV infection from the disease list is inconsistent with
leaving other sexually transmitted infections on the disease list. In
response, HHS/CDC acknowledges these comments, however as previously
stated, the basis for this regulatory change is based on solid
scientific knowledge and current public health practices. Additionally,
HHS/CDC is reviewing the other sexually transmitted diseases on the
disease list to determine whether additional revisions to Part 34 are
warranted.
In summary, HHS/CDC appreciates all the comments received on the
proposed change. After considering these comments, CDC has determined
that HIV infection is not a communicable disease that is a significant
risk for introduction and spread through casual contact to the general
U.S. population, where HIV infection already exists as an endemic
disease. Thus, HHS/CDC finalized the proposal to remove HIV infection
from the definition of communicable disease of public health
significance.

B. Comments on Removing HIV Testing From the Scope of Examinations

On the topic of removing HIV infection from the scope of
examinations, some commenters stated that mandatory testing for HIV
infection should no longer be required if they meet all other
conditions of admissibility. These commenters also noted that
maintaining testing while removing HIV infection from the definition of
communicable disease of public health significance is legally and
procedurally problematic. HHS/CDC maintains that it is appropriate to
remove HIV testing from the immigration process, since HIV infection
has been removed as a communicable disease of public health
significance. As previously stated, HHS/CDC also notes that the
regulations found at 42 CFR part 34 regulations do not specify testing
for any illness that is not included in the definition of communicable
disease of public health significance.
Other commenters stated that immigrants and refugees are not tested
for other expensive chronic diseases (i.e., diabetes, heart disease,
obesity) and so, maintaining testing for HIV is discriminatory and
would fuel the stigmatization of HIV-infected individuals. In response,
HHS/CDC notes that testing for those chronic diseases are not within
the scope of Part 34 regulations since they neither fall under the
diseases listed in the INA for the purpose of a medical examination for
U.S. immigration nor are they defined as a communicable disease of
public health significance. HHS/CDC notes that this regulatory change
will result in reducing stigma of HIV-infected persons.
Another group of commenters maintained that any mention of
serologic testing for HIV should be removed from the regulation. These
comments stated that (1) the entry ban for HIV infection amounted to
mandatory testing of all immigrants for HIV, which should not be
included in routine medical screening of aliens seeking admission into
the United States; (2) that people living with HIV should be allowed to
enter the United States or adjust to permanent resident status if they
meet all other conditions of admissibility; and (3) that when tested,
many immigrants do not receive adequate counseling and in some cases
have their privacy violated. For these reasons, these groups felt that
testing for HIV should be separate from the immigration process.
In response, HHS/CDC acknowledges these humanitarian concerns but
notes that HIV testing was required as a part of the 42 CFR part 34
rule when HIV infection was an inadmissible condition based on the
definition of communicable disease of public health significance. With
this final rule, HIV infection will no longer be contained in this
definition and HIV testing will not be required as part of the medical
examination.
Some comments in support of the proposed change to remove HIV
infection from the Part 34 regulations also stressed the importance of
HIV testing for immigrants and refugees for their own benefit and that
of their potential sexual partners (approximately 30 comments).
Specifically, several commenters said that testing for HIV enables
immigrants to receive counseling and education related to HIV/AIDS,
including information on treatment mechanisms and support systems, as
well as prevention. These individuals and groups submit that health
care outcomes are improved when testing is administered and access to
treatment is determined or planned prior to arrival. Improved outcomes
mentioned due to HIV testing prior to arrival included longer duration
until AIDS diagnosis, reduced onward HIV transmission, reduced risk of
active tuberculosis infection, and increased quality of life. In
response, HHS/CDC acknowledges that diagnosis and linkage to high
quality medical care in the context of the required immigration medical
examination could positively impact the health of persons with HIV
infection. HHS/CDC currently recommends and funds routine HIV screening
in medical settings for all U.S. residents, including immigrants in
contact with the health system.
Some individuals noted that in September 2006, HHS/CDC recommended
that all persons age

[[Page 56552]]

13-64 undergo testing at least once for HIV. They suggested that
keeping the HIV testing requirement for would-be immigrants would be
consistent with HHS/CDC existing policy, would help to meet the HHS/CDC
recommendation of voluntary testing, and would ensure that would-be
permanent residents were aware of their HIV status.
HHS/CDC appreciates these comments and emphasizes the importance of
adolescents and adults knowing their individual HIV status. However,
removing the requirement for HIV testing at the time of the medical
examination for immigration purposes will not prevent individuals from
knowing their status upon and after arrival in the U.S. CDC has and
will continue to work on a number of fronts to reduce the impact of HIV
across the nation by enhancing access to available prevention programs.
These program activities include expanding HIV testing to increase
knowledge of HIV status, improving surveillance to identify the leading
edge of the epidemic, and exploring innovative and promising new
prevention approaches. Communities and public health partners are
working to tailor prevention efforts to meet local needs, mobilize
communities, and expand the reach of HIV prevention. Further, Part 34
regulations do not specify testing for any disease that is not included
in the definition of communicable disease of public health
significance. For example, other recommended screening procedures such
as cholesterol tests, Pap smears, mammograms, or other diagnostic tests
for the presence of asymptomatic chronic health conditions such as
hepatitis B, are not conducted as part of the required medical
examination. CDC recognizes that the medical exam provides a unique
opportunity to both inform immigrants of their health status and, if
warranted, link them with care. If, as a part of the medical
examination for immigration, the panel physician detects a condition
that might warrant additional follow-up or testing, CDC will continue
to encourage the panel physician to inform the applicant about the
condition and to seek appropriate medical care and counseling services.
This would include anyone with symptoms suggestive of hepatitis, AIDS,
or other chronic infectious diseases that are not inadmissible
conditions.
Commenters also asked HHS/CDC to clarify how local public health
departments and voluntary agencies will be funded and equipped to
provide testing and counseling services to immigrants potentially
infected with HIV if HIV testing is no longer included in the required
medical examination for U.S. immigration. In response, HHS/CDC will
continue to work closely with its state and local partners in
protecting the public's health. HHS/CDC currently provides funding to
State and local health departments and community-based organizations
for outreach and HIV counseling and testing programs. Immigrants would
be eligible for services under these programs.
Some commenters suggested alternatives such as listing HIV
infection as a Class B health condition or another designation to
justify testing for immigrant applicants. In response, HHS/CDC
reiterates that Part 34 regulations do not specify testing unless the
illness is defined as a communicable disease of public health
significance.
In summary, CDC appreciates all the comments received on the
proposed change. After considering these comments, CDC has determined
that HIV testing will no longer be included in the scope of
examinations since HIV has been removed from the definition of
communicable disease of public health significance. Therefore, as
stated above, it is no longer necessary or appropriate to maintain HIV
in the scope of examinations.

C. Comments on the Economic Impact Analysis (EIA)

1. General Comments on the Cost Analysis
HHS/CDC received a number of comments from individuals and
organizations on the NPRM regarding the cost estimates of admitting
HIV-infected visitors and immigrants into the United States
(approximately 100). Many of the commenters complimented the quality of
the economic impact analysis and the level of transparency provided
regarding the methods and assumptions.
A majority of the individuals and organizations that provided
comments on the economic impact analysis supported the removal of HIV
infection from the list of communicable diseases as defined in 42 CFR
34.2(b), but suggested that the estimates provided in the NPRM
overestimate the cost of the proposed rule to the United States
taxpayer. Specifically, these individuals and organizations expressed
concerns that the NPRM estimates did not differentiate costs between
public and private payers; they noted that some HIV-infected immigrants
would secure private insurance, some would pay out-of-pocket, and some
would go without care or treatment. These commenters also noted that
there is no data available to support the assumptions that HIV-infected
immigrants will seek public benefits. They stated that all immigrants
entering the United States must document that they will not be a public
charge and immigrants do not have access to entitlement benefits for
five years.
Many of these commenters also noted that economic benefits of
removing the HIV ban were not included in the cost analysis.
Specifically, they noted that health care expenditures are a large
portion of the United States economy. Health care expenditures for
treatment of HIV infection contribute to the United States economy and
the creation of jobs. Similarly, some of these individuals and
organizations suggested that many HIV-infected immigrants will provide
revenue for the United States through taxes, visa fees, and
contributions to Social Security and that government-incurred expenses
currently used to enforce bans would be reduced. Some commenters also
noted that many immigrants would bring unique sets of skills and
abilities, that can contribute greatly to the United States workforce
and noted that these benefits were not captured in the analysis.
For these reasons, these individuals and organizations suggested
that the cost estimates presented in the NPRM inflated the public costs
of allowing HIV-infected immigrants into the United States. In other
words, these commenters suggested that the cost estimates in the NPRM
overestimate public sector expenditures resulting from this proposed
rule. HHS/CDC acknowledges these comments on the health care
expenditure estimates and recognizes that the estimates in the analysis
do not consider all factors and that there are some limitations to the
analysis.
Many of these individuals and organizations suggested that the cost
estimates were high, but they also noted that the assumptions upon
which the cost estimates were based were reasonable for this economic
analysis.
In response to these comments, HHS/CDC notes that the analysis was
not restricted to impacts to the U.S. Government. The HHS/CDC analysis
is an analysis of the health care sector expenditures taken from a
societal perspective. That is, all health care costs are included,
regardless of who pays. However, HHS/CDC also acknowledges that the
analysis is focused on the impact to the health care sector.
HHS/CDC acknowledges that the health care expenditures estimated in
the economic analysis may be small relative to the total heath care
sector in the U.S. Nonetheless, Office of Management and Budget (OMB)

[[Page 56553]]

Circular A-4 on ``Regulatory Analysis'' (available at: http://www.whitehouse.gov/OMB/circulars/a004/a-4.pdf) directs agencies to
assess all relevant impacts whether they be benefits, costs or
distributional (regardless of payer).
HHS/CDC also acknowledges that allowing immigrants to enter and
settle in the United States benefits the economy resulting from a
number of additional economic activities. However, we are unable to
quantify those potential benefits directly related to this rule.
Many organizations and individuals also noted that immigrants
infected with HIV may consume fewer health care resources than
immigrants with other chronic medical conditions. As such, these
commenters suggested that including the cost model in the NPRM
reflected inconsistencies in United States immigration policy.
Specifically, they noted that the costs of treating HIV are raised as a
concern in the proposed rule, but the costs of treating immigrants with
other chronic conditions are not considered when determining immigrant
status. In summary, they note that if the costs of treating immigrants
with other significant health concerns are not considered in
determining immigration policy, then HIV status should not be a factor
in setting immigration policy.
HHS/CDC appreciates these comments and acknowledges the points made
by these individuals and organizations. However, HHS/CDC conducted this
cost analysis in adherence to the Office of Management and Budget (OMB)
Circular A-4 requirements (available at: http://www.whitehouse.gov/OMB/circulars/a004/a-4.pdf).
Many of the individuals and organizations in opposition to the
proposed rule often cited concerns that the potential costs of the
proposed rule would result in an unacceptable, increased burden to the
United States tax payers and to the United States health care system.
HHS/CDC notes that the purpose of the rulemaking was to determine
whether HIV infection should remain as a communicable disease of public
health significance. Through this Final Rule, HHS/CDC notes that HIV
infection will no longer be a communicable disease of public health
significance, because scientific evidence suggests that it is not
transmitted through casual contact. Furthermore, we found no evidence
to support the assertion that the rule would impose an unacceptable,
increased burden on tax payers or the U.S. health care system.
One commenter noted that a significant number of visa applicants
are the immediate relatives of U.S. citizens, for whom there is no
numerical restriction. HHS/CDC acknowledges this point, but also notes
that most immediate relatives of U.S. citizens are eligible for waivers
under existing regulations. Much will depend on the assumed age
structure of family-related immigration (i.e., immigrants who are
granted landed immigrant status on the basis of uniting families) and
how many would have received a waiver absent this regulatory change.
However, HHS/CDC has no reliable data measuring existing demand (i.e.,
from family members who are HIV-infected and who will wish to immigrate
here due to the change in regulations).
Two reviewers noted CDC may have overstated the costs of the
proposed rule through calculation or transcription errors in the NPRM.
HHS/CDC thanks these reviewers for their careful review of the
analysis. HHS/CDC acknowledges that there was a transcription error and
made the necessary edits in the analysis for the final rule.
2. Comments on a Technical Review of the EIA
In addition to the general comments on the Economic Impact Analysis
(EIA), HHS/CDC also received a detailed technical review of the EIA
from commenters. The comments received on this review concluded that
the HHS/CDC cost assumptions were reasonable, but possibly overstated.
These reviewers also indicated that a 5-year time horizon for analysis
was reasonable.
This technical review noted that many of the economic benefits of
removing the HIV ban were not included in the cost analysis. These
reviewers further noted that the costs identified by HHS/CDC are health
care expenditures that may benefit rather than harm the economy and
suggest using a multiplier to estimate these economic benefits. One
reviewer also suggested that HHS/CDC wrongly assumes that there will be
no added economic benefit from new HIV-infected immigrants. The
reviewer also contented that these immigrants would contribute to the
economy and so the added health care expenditures CDC outlined would in
some part be offset.
Several reviewers also noted that the costs estimated by the HHS/
CDC model were small in proportion to the overall health care sector.
HHS/CDC acknowledges that data on the average annual health care
costs of HIV treatment for immigrants are limited and may be lower than
the estimates used in our analysis. We have added language which
indicates that the average annual medical costs for HIV treatment in
the Ryan White and Medicaid Programs range from $15,738 to $17,790 per
person. HHS/CDC also acknowledges that we did not include a
quantitative estimate of the economic benefits of removing HIV as an
inadmissible condition. We further acknowledge that the health care
expenditures have a direct impact on the health of individuals.
However, because no data exist to quantify these potential indirect
effects on the economy, we have not estimated these effects, either
through direct measurement or with the use of a multiplier.
HHS/CDC acknowledges that the health care expenditures estimated in
the economic analysis may be small relative to the total heath care
sector in the U.S. Nonetheless, OMB's Circular A-4 directs agencies to
assess all relevant impacts whether they be benefits, costs, or
distributional (regardless of payer).
One of the reviewers suggested that it would be helpful if HHS/CDC
explicitly stated that the costs to be borne by the federal government
are a fraction of the figure described as ``costs'' in the NPRM. The
reviewer also felt that it would be helpful if HHS/CDC would highlight
that the CBO analysis states that the government has already identified
a mechanism for offsetting the costs through visa fees.
The reviewer also suggested that the assumption that the prevalence
of HIV infection among those immigrating to the U.S. will be the same
as the prevalence in the general population of a particular region is
questionable. However, although the reviewer notes the lack of reliable
data may make this assumption reasonable, the reviewer believes that
the assumption is a likely overestimation.
This reviewer also suggested that the assumption that there are a
fixed number of immigrants is a flawed assumption because 40-47% of all
immigrants are not subject to numerical caps. Therefore, immediate
relatives would not replace an immigrant who is HIV negative. The
reviewer finally states that the assessment of the economic impact of
lifting the ban should also take into account the economic benefits.
HHS/CDC thanks the reviewer for the thoughtful and thorough
examination of the proposed rule and the economic model. The reviewer
is correct in the statement that all of the costs are not those to the
government. Consistent with OMB's Circular A-4, the HHS/CDC analysis is
an analysis of the health care sector costs taken from a societal

[[Page 56554]]

perspective; that is, all health care costs are included, regardless of
payer.
HHS/CDC acknowledges the uncertainty in the estimate of HIV
prevalence among immigrants who change their status to legal permanent
residents, and the argument can be made that the estimate of prevalence
should be higher or lower. Thus HHS/CDC chose to use a range. Further,
HHS/CDC acknowledges that the range is ``wide.'' However, HHS/CDC
believes that the range provides an important understanding of the
limitations of the available data.
The reviewer further commented that the model fails to account for
the economic benefits that those immediate family member immigrants
would bring to the U.S. economy. HHS/CDC notes that the purpose of the
HHS/CDC model was to account for the direct impact to the changes in
policy to the health care sector and not to account for ancillary
economic benefits. HHS/CDC also notes that although it thoroughly and
carefully examined the direct effects of the proposed rule change,
there are limitations to the analysis. Finally, HHS/CDC points out that
there is a limit on the number of immigrants allowed into the U.S. each
year. Family-related immigration is usually outside those limits.
Again, HHS/CDC acknowledges that it has no reliable data measuring the
existing demand among families to reunite with their loved ones. In
addition, HHS/CDC notes that this point is probably only valid for an
initial period following the change in regulations, where there would
be a catch-up phase.

D. Comments on Technical Correction

Two comments were received that provided the following technical
correction: ``In section II, Background, part I (p. 31798), last
sentence, the proposed rule should state that the grounds of
inadmissibility for specific health related grounds also pertain to
most aliens in the United States who are applying for adjustment of
their status to that of lawful permanent resident. There are few
exceptions, e.g., applicants under INA 249, 8 U.S.C. 1259 (registry) or
under INA 245, 8 U.S.C. 1255 (m) (U nonimmigrant status/U visa holders)
are exempt from the health-related grounds of inadmissibility at INA
212(a)(1)(A), (8 U.S.C. 1182 (a)(1)(A))''. CDC has accepted this
technical change and amended the preamble text to reflect this.

VI. Conclusions and the Final Rule

Therefore, HHS/CDC amends 42 CFR 34 as follows: HIV infection is
removed from the definition of a communicable disease of public health
significance as defined in 42 CFR 34.2(b), and references to HIV are
removed from the scope of examinations in 42 CFR 34.3. As a result,
beginning on the effective date of this rule, HIV infection will no
longer be an inadmissible condition, and HIV testing will no longer be
required for those aliens who are required to undergo a medical
examination for U.S. immigration purposes.
HHS/CDC has considered the rationale for all the public comments on
the proposed rule. The vast majority of comments support the NPRM as
written, with less than 3% of all commenters opposed to the changes in
the NPRM.
HHS/CDC believes that the positive benefits of this regulatory
change outweigh the costs. After considering public comments, as well
as the most recent scientific and public health data available, HHS/CDC
has decided to promulgate the final regulation as proposed in the NPRM.
HHS/CDC will revise the Technical Instructions provided to panel
physicians and civil surgeons, as needed, regarding the removal of
required HIV testing, and this information will also be immediately
available to the public on the HHS/CDC Division of Global Migration and
Quarantine Web site, located at the following Internet address: http://www.cdc.gov/ncidod/dq/technica.htm. HHS/CDC will also work with DoS and
DHS to ensure that panel physicians and civil surgeons respectively are
aware of the revision to the Technical Instructions regarding the
removal of required HIV testing.

VII. Required Regulatory Analyses Under Executive Order 12866

HHS/CDC has examined the impacts of the proposed rule under
Executive Order 12866 and the Regulatory Flexibility Act (5 U.S.C. 601-
612), and the Unfunded Mandates Reform Act (Pub. L. 104-4). Executive
Order 12866 directs agencies to assess all costs and benefits of
available regulatory alternatives and, when regulation is necessary, to
select regulatory approaches that maximize net benefits (including
potential economic, environmental, public health and safety, and other
advantages; distributive impacts; and equity). The agency believes that
this final rule is an economically significant action under the
Executive Order.
In the analysis that follows, we assess the potential impacts of
removing HIV infection from the list of specific communicable disease
of public health significance and removing the HIV testing requirement
in the medical examination for aliens who are applying for adjustment
of their status to that of a lawful permanent resident.

A. Objectives and Basis for the Action

Prior to the enactment of the United States Global Leadership
Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of
2008, HHS/CDC was required by statute to list HIV infection as a
``communicable disease of public health significance.'' Now that the
statute provides discretion, HHS/CDC is taking this action to reflect
current scientific knowledge and public health best practices, and to
reduce stigmatization of people who are HIV-infected. This final rule
is not intended to correct any market failure, but to remove a
government-imposed barrier that does not provide a significant public
health benefit.

B. Alternatives

HHS/CDC examined three regulatory approaches.
1. The first approach is to maintain HIV infection on the list of
communicable disease of public health significance, i.e., to keep the
disease as an inadmissible condition for entry into the U.S. This means
that visa applicants seeking permanent residency would continue to
undergo testing for HIV infection as part of the application process.
Those applicants testing positive for HIV, if eligible, would still be
required to apply for and obtain a waiver from DHS prior to coming to
the U.S. There are several disadvantages to this approach. As stated
previously, while HIV infection is a serious health condition, it does
not represent a communicable disease that is a significant risk for
introduction, transmission, and spread to the U.S. population through
casual contact. Currently, there are already roughly 1 million persons
in the United Stated living with HIV [1]. Thus, maintaining HIV
infection on the list of inadmissible conditions for entry into the
U.S. would not result in significant public health benefits. Further,
this approach is not in line with current international public health
practice. This approach contributes toward the stigmatization of HIV-
infected persons. HHS/CDC did not select this approach.
2. The second approach is to remove HIV infection from the list of
communicable disease of public health significance, i.e. remove it as a
ground of inadmissibility into the U.S., but continue mandatory HIV
testing for all immigrant applicants similar to an approach followed by
some countries. Under this approach, all those aliens

[[Page 56555]]

who test positive for HIV infection could be informed of their HIV
status, counseled regarding their condition, the need for appropriate
treatment, and the steps that should be taken to minimize the risk of
onward transmission.
There are potential public health benefits to a mandatory testing
approach. The medical examination offers a unique opportunity to both
inform immigrants of their HIV status and link them with care. Through
screening, HIV-infected aliens who are potentially unaware of their HIV
status would become aware of their status and could be linked with
prevention, care and treatment options in the United States. Early
diagnosis and treatment of HIV-infected persons can increase life
expectancy and may improve the quality of life. Additionally, knowing
one's HIV status decreases the likelihood of onward transmission [2,
3]. These public health benefits are the basis for the HHS/CDC's
``Revised Recommendations for HIV Testing of Adults, Adolescents, and
Pregnant Women in Health-Care Settings,'' which states that the
characteristics of HIV infection are consistent with all generally
accepted criteria that justify voluntary screening [4]. However,
mandatory HIV testing is limited to certain infrequent cases such as
blood and organ donors.
There are also disadvantages to continued mandatory testing if HIV
infection is removed from the definition of communicable disease of
public health significance. Mandatory testing for other serious health-
related conditions that are not inadmissible health conditions, (e.g.,
infectious diseases, such as hepatitis, malaria, and West Nile virus
and chronic conditions such as diabetes and heart conditions), are not
required as part of this medical examination. Thus, continued mandatory
HIV testing would differentiate HIV infection from other serious
health-related conditions. Second, although the purpose of the medical
examination is to identify health conditions considered inadmissible on
public health grounds, the results of examinations conducted by panel
physicians in the immigrant's home country might not be kept
confidential because of requirements in the country of origin making it
necessary to report HIV results to local authorities. These results may
be counter to HHS/CDC objectives of reflecting current scientific
knowledge and public health best practices, and reducing stigmatization
of people who are HIV-infected. Therefore, as discussed below in the
third approach, HIV testing, consistent with CDC's recommendations for
general screening, would be available.
3. The third approach is to remove HIV infection from the
definition of communicable disease of public health significance and as
a requirement in the medical examination. This means that mandatory
testing for HIV infection would no longer be required and DHS would
allow HIV-infected persons to enter into the U.S. (or to adjust to
permanent resident status) if they meet all other conditions of
admissibility. This is the regulatory approach that HHS/CDC selected.
Along with this approach, all immigrants, refugees and status adjusters
would still have the opportunity to receive information about HIV
testing and to be tested in the United States as recommended by the CDC
guidelines [4]. The discussion of the potential impacts of the rule
that follow relate to this approach.

C. Baseline and Incremental Analysis

The baseline for this analysis assumes no change in the current
regulation. In other words, all applicants for admission into the U.S.
as legal permanent residents and those already within the U.S. seeking
adjustment to permanent resident status are currently tested for HIV
infection during the immigration medical examination. Those who are
HIV-infected and are not granted a waiver by the Department of Homeland
Security are refused lawful permanent resident status in the United
States.
Currently, refugees who are HIV-infected must be granted a waiver
by the Department of Homeland Security before entering the U.S.
Subsequently, refugees infected with HIV who are present in the U.S.
and apply for adjustment to permanent resident status must be re-
examined and granted another waiver from DHS at that time (i.e., the
grant of waivers permits these individuals to obtain refugee status,
and later, permanent resident status despite being HIV-infected, which
would otherwise render them inadmissible). We have not explicitly
included groups other than lawful permanent residents (e.g. refugees)
in our analysis, however, because: (i) These persons, compared to the
other immigrants, enter the U.S. under extraordinary circumstances;
(ii) the numbers are relatively small; and, (iii) the proposed change
in regulations is not likely to have a significant impact on the annual
number of HIV-infected refugees admitted to the U.S. and who later
become permanent residents because such persons generally receive a
waiver of inadmissibility for HIV infection under current procedures.
Thus, the numbers of admitted HIV-infected refugees who are
subsequently granted permanent resident status are likely to stay the
same, regardless of regulations in place. That is, the HIV-infected
refugees-turned-permanent residents are part of the baseline scenario.
Furthermore, though this policy would increase the total number of
people who may be eligible to be admitted, we assume that the total
number of immigrants who are annually admitted into the United States
is fixed over time. Thus, the incremental input to the rule is a
calculation of the additional costs due to HIV-infected immigrants
above the costs of non-HIV-infected immigrants. In general, given that
the total number of immigrants is not likely to change and the share of
HIV-infected immigrants is likely to be relatively small, the rule will
not likely have an appreciable impact on the economy in terms of wages,
productivity, or prices of goods and services.

D. Defining the Population Affected

The affected population is defined as the number of new HIV-
infected lawful permanent residents entering the United States each
year and those individuals already in the United States seeking to
adjust their immigration status to that of a lawful permanent resident.
The proposed changes in 42 CFR part 34: Medical Examination of Aliens
affects all foreign nationals entering the U.S. who are infected with
HIV. Although HIV testing is not routinely required for entrance into
the U.S. except for those aliens who are seeking to become lawful
permanent residents, visitors who are infected with HIV are currently
required to request waivers to obtain entrance. With this final rule,
the waiver process will no longer be necessary. Data on the number of
waivers granted annually based on HIV status are not available. For
example, in Fiscal Year 2007, the Department of State reported that its
consular officers found 746 applicants for immigration ineligible for
admission to the U.S. under the communicable disease grounds of INA
212(a)(1)(A)(i). The number of applicants who tested positive for HIV
infection is unknown. This analysis is limited to aliens seeking to
become lawful permanent residents who are required to have a medical
examination to determine admissibility. Because applicants such as
visitors and refugees have historically had the option of obtaining a
waiver to enter and remain in the U.S., these groups are not included
in this analysis.
Based on the estimated distribution of HIV/AIDS cases in each of
the regions in the world and weighted by the

[[Page 56556]]

number of immigrants entering the United States from each region, we
estimate that approximately 4.06 (range of 1.02 to 6.09) immigrants per
1,000 immigrants that would be likely to enter the U.S. under the
proposed rule would be infected with HIV (see Table 1 for the summary
of regional estimates and weights and Technical Appendix II, Table 1:
Summary of Model, HIVEcon, Inputs and Assumptions for Primary, Lower
and Upper Bound Analyses [5]).

Table 1--Regional Population, Immigration and HIV Estimates Used To Calculate the Weighted Regional Rate Estimates
--------------------------------------------------------------------------------------------------------------------------------------------------------
Estimate of HIV rate per 1,000 (based Estimated number of HIV-infected
Legal on 2006 regional population estimates immigrants
permanent [7] and 2007 HIV regional estimates --------------------------------------
residents [8])
(2007) [6] --------------------------------------- Primary Low High
Primary Low High
--------------------------------------------------------------------------------------------------------------------------------------------------------
Africa *..................................................... 96,105 18.05 16.70 19.57 1,735 1,605 1,880
Asia......................................................... 383,508 1.29 1.05 1.63 494 403 624
Europe....................................................... 120,821 3.23 2.46 4.38 390 297 529
N. America................................................... 339,355 3.84 1.42 5.61 1,302 481 1,903
Oceania...................................................... 6,101 2.19 1.55 3.50 13 9 21
S. America................................................... 106,525 3.20 2.81 3.79 341 300 404
Total........................................................ 1,052,415 4.98 4.35 5.73 ........... ........... ...........
--------------------------------------------------------------------------------------------------------------------------------------------------------
HIV positive Rate per 1,000 U.S. immigrants [dagger]......... ........... 4.06 [Dagger] [Dagger] 4,275 3,096 5,361
2.94 5.09
--------------------------------------------------------------------------------------------------------------------------------------------------------
* In this case, Africa includes North Africa, the Middle East and Unknowns.
** Total number of adults and children living with HIV in the region (see Technical Appendix II for more detail [5]).
[dagger] Based on weighted regional estimates. The assumption is that prevalence of HIV amongst immigrants to the U.S. mirrors that of the immigrant's
native regions and is adjusted for the number of immigrants coming to the U.S. from each region.
[Dagger] Note: these estimates represent the 5th and 95th percentiles based on regional weight estimates. Due to concern that immigrants may not be
representative of the typical country level estimates and thus may be outside the confidence interval, for purposes of this analyses we expanded our
confidence interval to 25% to 150% of the Primary estimate (i.e. 1.02 to 6.09 HIV+ immigrants per 1,000 immigrants).

The numbers of HIV/AIDS persons in each region of the world were
taken from the 2007 AIDS Epidemic Update: Global Overview issued by the
Joint United Nations Programme on HIV/AIDS (UNAIDS)[8]. HHS/CDC used
regional data and rates that were determined using the regional
population data from 2006 published by the Population Division of the
Department of Economic and Social Affairs of the United Nations
Secretariat [7]. After examining the immigration data, by region, from
the Yearbook of Immigration Statistics: 2007 Immigrants [6], we
assigned regional weights according to the number of aliens coming to
the United States from each region.
The 2007 Immigration Statistics [6, 9] indicate that 1,052,415
persons became permanent residents in 2007. Multiplying this number by
our prevalence estimate of 4.06 (range of 1.02 to 6.09) HIV-infected
immigrants per 1000 immigrants yields an estimated 4,275 (range of
1,073 to 6,409) HIV-infected immigrants who would enter into the United
States each year.
However, we note that there are significant uncertainties in this
estimate since no specific data exist on the HIV prevalence of persons
seeking to immigrate to the United States. We do not have a basis to
judge how these immigrants who qualify for permanent residence differ
from the general regional population in terms of HIV prevalence; thus,
for the purposes of this analysis we assumed that it would be
equivalent to the regional HIV prevalence rates. We used regional HIV
prevalence rates rather than HIV rates for specific countries to allow
for year to year variations in the number of aliens entering the U.S.
from specific countries.
There are several possible reasons as to why the proportion of HIV-
infected immigrants could be less or more than the prevalence of HIV-
infected persons in the region of origin. For example, the cost of
adequate medical care in the U.S. may make HIV-infected individuals
reluctant to immigrate to this country. With the increase in the
availability of appropriate HIV treatments in many parts of the world,
adequate treatment is often cheaper outside of the U.S. Conversely, in
regions or specific countries where appropriate treatment is less
readily available, the portion of HIV-infected immigrants from those
regions could be higher than the prevalence of HIV-infected persons in
that region.
We used a range of 1.02 to 6.09 HIV-infected persons per 1,000
immigrants based on 25% and 150% of the mean weighted average--4.06 per
1,000 immigrants of the number of estimated HIV-infected persons in
each region but weighted by the number of lawful permanent residents
who entered the U.S. in 2007. This range yields a lower bound estimate
of 1,073 and an upper bound estimate of 6,409 HIV-infected persons
entering the United States annually (see Technical Appendix II [5]).

E. Analysis of Impacts

In this final rule, HHS/CDC is removing HIV infection from the
definition of communicable disease of public health significance
contained in 42 CFR 34.2(b) and scope of examination, 42 CFR 34.3
because HIV infection does not represent a communicable disease that is
a significant threat to the general U.S. population. The rationale for
maintaining HIV infection as an inadmissible condition is no longer
valid based on current medical knowledge and public health practice,
scientific knowledge, and experience which has informed us on the
characteristics of the virus, the modes of transmission of HIV, and the
effective interventions to prevent further spread of the virus. To the
extent the final rule will result in an increased number of HIV-
infected immigrants to the U.S. each year, there will be quantifiable
impacts. We have made our best attempt to capture the likely effects of
the rule, but there are significant uncertainties in this estimation
effort.
1. Potential Benefits
The benefits from this action are difficult to quantify. Based on
the estimate above, this rule would allow perhaps roughly 4,275 (range
of 1,073 to

[[Page 56557]]

6,409) persons to enter the United States annually who are otherwise
admissible but are denied admission solely based on their HIV status.
The rule will bring family members together who had been barred from
entry, thus strengthening families. Also, HIV-infected immigrants with
skills in high demand would be permitted to enter the U.S. to seek
employment and contribute as productive members of U.S. society.
Depending on the region of the world from which a person emigrates,
admittance to the U.S. may afford greater opportunity, better health
care, and education and training programs than those available in the
immigrant's home country. These HIV-infected individuals, compared to
those who do not receive appropriate multi-drug anti-retroviral therapy
for HIV treatment, could survive an additional 13 years, with an
average life expectancy of approximately 29 years (to age 49 years)
[10]. This increased life expectancy allows the opportunity for longer
and improved productivity.
Further, this final rule removing HIV infection from the definition
of communicable disease of public health significance and from the
scope of examinations will remove stigmatization of HIV-infected people
who have long been denied entry into the U.S. based only on a treatable
and preventable medical condition. This proposed rule will bring the
U.S. in line with current science and international standards of public
health.
Though this rule is assumed to not have an impact on the total
number of immigrants annually admitted as legal permanent residents, we
note that immigration, in general, produces net economic gains for the
United States.[11].
2. Impact on Health Care Expenditures
As previously noted, we have made our best attempt to capture the
likely effects of the rule, but there are significant uncertainties in
this estimation effort. HHS/CDC notes that this analysis is an analysis
of the health care sector costs taken from a societal perspective; that
is, all health care costs are included, regardless of payer. The costs
to be borne by the Federal government are only a part of the total
costs described below.
As previously discussed, the incremental impacts of the rule should
be a comparison between the arrival of an HIV-infected immigrant and
the arrival of an HIV-negative immigrant. Presumably, HIV-related
health care expenditures will be different, but there are a variety of
health expenditures that the HIV-infected immigrant may not incur that
other immigrants may incur (e.g., certain types of cancer, diabetes,
heart disease). It is not clear that, over the course of a lifetime, on
net an HIV-infected immigrant would consume more health care resources
than other immigrants. Furthermore, HIV treatment yields benefits that
off-set the expenditures, including increased life expectancy and
productivity.
However, given that health care expenditures associated with
treatment of HIV infection can be substantial and may result in some
fiscal impacts (as discussed below), we developed a model (HIVEcon) to
estimate these potential effects of the rule. A complete description of
the model including assumptions, results and limitations is available
for examination [5]. The spreadsheet model itself is also available for
download so that the reader can determine the relative impact of
altering almost any input value, individually or several simultaneously
[12].
The model, HIVEcon, examines the treatment costs as estimated by
Schackman et al [13] associated with newly identified persons infected
with HIV regardless of payer, following the 2004 standards of care. The
annual treatment cost is estimated to be $25,200 in 2004 dollars, with
a range of $19,466 to $30,954. However, significant advances in the
treatment of HIV have been made since 2004 [14], and are likely to
continue to be made. Thus, the expenditure estimates could be
underestimated since as treatment options increase, the benefits such
as quality of life and lifespan will increase as will costs. However,
these expenditures may be overestimated since it is not clear to what
extent immigrants will seek and receive even the 2004 standard of care.
Expenditures may also be overestimates if only including direct medical
costs, as is done for the Ryan White Block Grant and Medicaid Programs,
where average annual costs range from $15,738 to $17,790 per person.
The absolute lower bound estimate is $19 million in the first year
(decreasing the prevalence rate to 1.02 HIV+ immigrants per 1,000
immigrants and the average annual medical expenditures to $19,466). The
maximum upper bound estimate is $173 million (increasing the prevalence
rate to 6.09 HIV-infected immigrants among 1,000 immigrants, and the
average annual medical expenses to $30,954 per immigrant). In the
HIVEcon model, in Year Two following the change in regulation, as the
cumulative number of HIV-infected immigrants almost doubles, so will
these annual health expenditures. Likewise in the third year, the
expenditures will be equivalent to three years' worth of immigrants
(excluding those who have passed away) and so on until the HIV-infected
immigrants reach their life expectancy (e.g., in the model, an HIV-
infected person at age 30 has an average life expectancy of 24.7
years).
3. Comparison With Congressional Budget Office Analysis
The Congressional Budget Office (CBO) estimated the cost to the
federal government of Section 305 of PL 110-293 prior to the law's
enactment. The analysis included increases in direct spending related
to provision of health care and other benefits paid for by the federal
government. Specifically, those benefits include Medicaid, Supplemental
Security Income, Food Stamps, and nutritional programs. In total, CBO
estimated that providing these benefits to HIV-infected immigrants and
their citizen children will increase spending by less than $500,000 in
2010 and $83 million over the 2010-2018 period, primarily for Medicaid.
The CBO analysis was done for the purpose of estimating the impact
of PL 110-293 on the federal budget. The analysis for this final rule
was done to comply with Executive Order 12866, which directs agencies
to assess all costs of available regulatory alternatives, including,
but not limited to, those costs incurred by the federal government. The
economic analysis for this regulation differs from the CBO analysis for
PL 110-293 in four major areas: (1) The CBO analysis assumed that the
HIV prevalence rate would be equal to half of the weighted-average HIV
prevalence rate for the immigrants' country of origin, whereas this
analysis assumed that the HIV prevalence rate would be equal to the
weighted-average rate of the immigrants' region of origin; (2) the
number of immigrants was increased by 5% each year in the CBO analysis
while this analysis did not include growth in the annual number; (3)
the CBO analysis only examined health care costs paid for by Medicaid
whereas this analysis included all health care costs including those
paid for by the Ryan White Program; and (4) the CBO analysis included
costs of federal disability and nutrition benefits, whereas this
analysis did not include those costs.
By the year 2013, the number of HIV-infected immigrants entering
the U.S. projected by the CBO analysis is roughly equivalent to that
projected by this analysis (analytical differences in prevalence and
growth rates cancel out). By 2018, the number of HIV-infected

[[Page 56558]]

immigrants projected by the CBO analysis exceeds projections in this
analysis. The health care costs in this analysis exceed that of CBO's
analysis because the former included all federal and nonfederal costs
including those costs paid for through the federally-funded Ryan White
Program. This analysis did not include non-health care costs.
4. Potential Fiscal Impacts
As previously discussed, even if HIV-related health restrictions
are removed as a barrier to admission for immigrants, all immigrants
still must meet other admission requirements. In the United States,
under the Federal Personal Responsibility Work and Opportunity
Reconciliation Act (PRWORA) of 1996, most immigrants are not eligible
to receive means-tested public benefits for five years after their
entry into the U.S. [15, 16]. Federal means-tested public benefits
include Supplemental Security Income (SSI), cash Temporary Assistance
for Needy Families (TANF), Medicaid, and food stamps [15, 17]. State
and local means-tested benefits are determined at the state or local
level and vary by jurisdiction. We have no data to assume that HIV-
infected immigrants will seek, five years after being admitted to the
U.S., such benefits at rates different from non HIV-infected
immigrants.
In addition, PRWORA placed other limitations on aliens' access to
public benefits, making them more difficult for aliens to obtain. For
example, the income and resources of the sponsor of a family-based
immigrant or permanent resident are deemed to be available to that
alien if he/she should apply for certain means-tested public benefits.
See 8 U.S.C. 1631, 1632. Since a sponsor must first prove to DHS that
he/she is able to provide support to the sponsored alien at an annual
income that is at least 125% above the federal poverty level before the
alien's immigration application will be approved, it is unlikely that
the alien will be able to show that his/her available resources fall
beneath the low income eligibility thresholds required for many means-
tested public benefits. See INA section 213A(a)(1)(A).
However, some immigrants may be eligible for certain assistance
through the Ryan White HIV/AIDS Program--a federally-funded program
that provides HIV-related health services. Funds are awarded to
agencies located around the country, which in turn deliver care to
eligible individuals. Since the program is administered through
different grantees using different eligibility criteria, it is
difficult to assess the extent the HIV-infected immigrants will be
eligible for assistance through this program. However, given that the
estimated number of new HIV-infected immigrants entering the United
States as a result of this rule is relatively small compared to the
total number of persons currently assisted by the funding (roughly half
a million), the overall impact on the program is likely small.
5. Onward Transmission
Though difficult to quantify with precision, there will likely be
some additional cases of HIV infection due to onward transmission from
HIV-infected immigrants to others in the United States who are not
currently infected. The costs associated with onward transmission
include:
Shortened lifespan and reduction in quality of life even
with treatment,
The health care costs associated with treating HIV
infection,
The costs of social services when individuals are unable
to fully support themselves because of their illness, and
Decreased productivity when individuals become too sick to
work.
Because health care costs are substantial and other costs listed
above are difficult to quantify, the analysis in the HIVEcon model is
limited to health care costs associated with treatment of HIV
infection.
In the model, the number of estimated HIV-infected cases due to
onward transmission (in Year t) is calculated as: [(Number of HIV-
infected immigrants entering in Year t + Number of HIV-infected
immigrants surviving from previous years that survive to Year t +
additional persons previously infected by onward transmission from HIV-
infected immigrants that survive to Year t) x onward transmission
rate].
A 1.51% onward transmission rate was used in the HIVEcon model to
represent the annual estimated number of new infections caused by HIV-
infected immigrants to the U.S., or caused by U.S. person infected by
HIV-infected immigrants (i.e., annually every 100 HIV-infected persons
infect an additional 1.51 persons). The most recent estimate of average
onward transmission, when limited to sexual transmission, in the United
States is 3.02 per 100 HIV positive immigrants [18]. In 2006, the
overall rate for onward transmission of HIV in the U.S. from all
causes, was 5 new infections per 100 HIV-infected persons [19]. Results
from published research indicate that immigrants to the United States,
regardless of their race or ethnicity, often have an initial better
health profile than native-born Americans across diverse health
behaviors and outcomes; however, this health advantage declines as
length of residence in the United States and degree of acculturation
increase [20-26]. Specifically, studies of HIV risk behavior among
immigrant populations, upon arrival in the U.S., indicate that these
behaviors are influenced by a number of factors including the
demographic characteristics of the migrants (especially sex, social
class, relationship status and education); the purpose of immigration;
the type and location of their receiving community and the existing
supports; discrepancy between pre-immigration expectations and post-
immigration experiences; and transnational movement between the U.S.
and their home countries [27-31]. These multiple factors result in
heterogeneity in HIV risk between migrant communities, with some being
at lower, and others higher risk, than their U.S. counterparts. There
is no evidence to suggest immigration to the U.S. significantly affects
HIV incidence in this country in one direction or the other. Thus, it
is not unreasonable to assume that onward transmission rates amongst
HIV-infected immigrants will be lower than among HIV-infected persons
born in the U.S.
For this analysis, we assumed that the onward transmission rate for
immigrants, and those that they infect, would be fifty percent of the
average U.S. rate for sexual transmission (i.e., rate of onward
transmission from HIV-infected immigrants is assumed, in the baseline
case, to be 1.51 per 100). Because data supporting this assumption are
limited, this assumption was tested in sensitivity analysis. We used 0%
transmission as our lower bound estimate and a transmission rate of
4.53 per 100 HIV-infected immigrants, and those that they infect, as
our upper bound estimate. The upper bound transmission rate is a fifty
percent increase in the average annual onward transmission rate of
3.02%.
Assuming 4,275 HIV-infected immigrants enter in the first year,
there will be 65 new HIV infections due to onward transmission,
assuming an onward transmission rate of 1.51 per 100 HIV, with a range
of 0 to 261 (assuming onward transmission of 0 and 4.53 per 100 HIV-
infected immigrants, respectively). These estimates imply treatment
costs, for those infected via onward transmission only, in the first
year of $1.6 million in the primary estimate and a range of $0 to $8.1
million [5].
For the purposes of calculating new HIV infections associated with
HIV-infected immigrants in the U.S., HIVEcon adds persons infected by
HIV-

[[Page 56559]]

infected immigrants to the cohort of projected HIV-infected immigrants.
This modeling technique represents the chain of onward transmission
after initial transmission from an HIV-infected immigrant. Thus, in the
next year, though the cumulative number of HIV-infected immigrants
essentially doubles, the number of new HIV cases (as well as the
associated treatment costs) will be slightly more than double the
previous year.
This modeling approach assumes that those people infected by HIV-
infected immigrants would never have become infected with HIV were it
not for the arrival in the U.S. of HIV-infected immigrants. This could
be unrealistic since U.S. persons who are infected by HIV-infected
immigrants may engage in behaviors that lead them to activities that
expose them to HIV infections, regardless of the source of infection.
An alternative interpretation may be that at least some of the
additional infections are occurring earlier than they otherwise would
have. Thus, these shifts in the timing of infection will increase the
total number of new cases in any one year, but the true incremental
impact may be the implications of becoming infected earlier.
Furthermore, the model treats the onward transmission rate as fixed
over time. However, data show that onward transmission has declined
over time[19]. If we assume that transmission rates will continue to
decrease in the future, it is possible that the model may overestimate
the number of HIV-infected individuals due to onward transmission as we
project impacts into the future.

F. Summary of Impacts

We have made our best attempt to capture the likely effects of the
rule, but there are significant uncertainties in this estimation
effort. For example, the HIVEcon model projects potential impacts out
to 50 years after the rules go into effect. However, many of the key
inputs to the model may be significantly different even ten years from
now given the rapid pace of change in HIV treatment, HIV prevalence in
other countries, as well as potential changes in the overall
immigration policy. It may not be inconceivable that there would be an
HIV vaccine in the next decade or two. Given these and other
uncertainties, Table 2 provides a summary of the potential effects of
the rule five years after implementation.

Table 2--Summary of Impacts (Year Five After Implementation), Assuming the Average Age of Entry is 30 Years and
the Annual Discount Rate is 3%
----------------------------------------------------------------------------------------------------------------
Primary estimate (4.06 Low estimate (1.02 HIV+ High estimate (6.09
Category HIV+ immigrants per immigrants per 1,000 HIV+ immigrants per
1,000 immigrants) immigrants) 1,000 immigrants)
----------------------------------------------------------------------------------------------------------------
BENEFITS
----------------------------------------------------------------------------------------------------------------
Total number of HIV-Positive 15,755................. 3,956.................. 23,622
Immigrants present in the U.S. at
year five who would not otherwise be
able to immigrate.
----------------------------------------------------------------------------------------------------------------
Qualitative.......................... 1. Will reduce stigmatization of HIV-infected people.
2. Will bring family members together who had been barred from entry,
thus strengthening families.
3. Will permit HIV-infected immigrants with skills in high demand would
be permitted to enter the U.S. to seek employment and contribute as
productive members of U.S. Society.
4. Compared to those who don't receive appropriate multi-drug anti-
retroviral therapy, survive an additional 13 years, with an average life
expectancy of approximately 29 years (to age 49 years) [10]. This
increased life expectancy allows opportunity for longer and improved
productivity.
----------------------------------------------------------------------------------------------------------------
COSTS
----------------------------------------------------------------------------------------------------------------
Total number of HIV-Positive cases 676.................... 170.................... 1,014
due to 1.51% onward transmission
connected with U.S. Immigrants.
Annualized Monetized Health care $14 million............ $4 million............. $22 million.
Expenditures from onward
transmission.
----------------------------------------------------------------------------------------------------------------
Qualitative.......................... 1. Shortened lifespan and reduction in quality of life even with
treatment.
2. Decreased productivity.
----------------------------------------------------------------------------------------------------------------
TRANSFERS
----------------------------------------------------------------------------------------------------------------
Annualized Monetized Health care $342 million........... $86 million............ $513 million.
Expenditures.
----------------------------------------------------------------------------------------------------------------
Share for Federal Payers............. Depends upon assumptions of who pays annualized monetized medical costs;
likely to be small given restrictions on Federal assistance to new
immigrants.
----------------------------------------------------------------------------------------------------------------
Notes: Source of estimates see Figures 1, 3, and 4 in Technical Appendix II [5].

The primary benefit of this rule is that each year an additional
4,275 (range of 1,073 to 6,409) immigrants who otherwise qualify for
entry but are denied based solely on HIV status will now be able to
enter the country. Although we are unable to quantify all of the
benefits of this change in policy, we believe it will help reduce
stigmatization of HIV-infected people; bring family members together
who had been barred from entry (thus

[[Page 56560]]

strengthening families); and allow HIV-infected immigrants with skills
in high demand to enter the U.S. to seek employment and contribute as
productive members of U.S. society, and if they are able to obtain
better health care in the United States, to improve health outcomes and
productivity. There are also ethical, humanitarian, distributional, and
international benefits that are important but difficult to quantify.
[We note the words of Executive Order 12866: ``Costs and benefits shall
be understood to include both quantifiable measures (to the fullest
extent that these can be usefully estimated) and qualitative measures
of costs and benefits that are difficult to quantify, but nevertheless
essential to consider.''] We observe as well that in the context of the
U.S. HIV/AIDS prevalence, currently estimated at roughly 1 million
persons [1] the 3,956 to 23,622 HIV-infected immigrants in five years
represents 0.4% to 2.4% of the national total of persons living with
HIV/AIDS.
The main cost of this rule is the potential for onward transmission
to U.S. residents who are not infected with HIV. As we noted in the
previous discussion, however, our modeling approach assumes that those
people infected by HIV-infected immigrants would never have become
infected with HIV were it not for the arrival in the U.S. of HIV-
infected immigrants. This assumption will in some cases be unrealistic,
because U.S. persons who are infected by HIV-infected immigrants may
engage in behaviors that expose them to HIV infections, regardless of
the source of infection. It is possible, of course, that at least some
of the additional infections are occurring earlier than they otherwise
would have. To the extent that this is so, the shifts in the timing of
infection will increase the total number of new cases in any one year,
but the true incremental impact may be the implications of becoming
infected earlier.
Furthermore, the model treats the onward transmission rate as fixed
over time. However, data show that onward transmission has declined
over time [19]. Even given these caveats, in the context of the new
U.S. incidence of HIV, currently estimated at roughly 56,000 [32], the
number of new onward transmission cases due to the rule change, 65
(ranging from 0 to 261) in year one represent 0.1% (ranging from 0 to
0.5%) of the total new annual cases of HIV in the U.S. (as described in
Section 5. Onward Transmission). The monetized costs including the
treatment cost of the onward transmission cases, are relatively modest.
We add, however, that these monetized costs are incomplete, because
they do not include the health costs in terms of reduction in quality
of life and longevity even with treatment.
On the other hand, health care expenditures for immigrants,
although a quantifiable and relevant impact of the rule, are not really
``costs'' of the rulemaking. Unlike in the case of onward transmission,
these immigrants already have the disease and will now be purchasing
healthcare in the U.S. that they would have purchased in their home
country (similar to spending on other services such as housing or
education). However, since the spending pattern may be systematically
different for HIV immigrants, we quantify and report these effects as a
``transfer'' from the perspective of this rulemaking--payments from
immigrants and/or their 3rd party payers to U.S. providers of care. We
estimate the annual transfer payments to be $86 million to $513
million. The share of these payments by Federal payers is likely to be
small given the restrictions on Federal benefits to new immigrants.
Given these potential impacts, we conclude that the benefits of the
rule justify its costs, and that while we do not believe HIV is a
``communicable disease of public health significance'' for the purposes
of admissibility determinations, the rule may be economically
significant.

G. Literature Cited

1. CDC, HIV prevalence estimates--United States, 2006. MMWR Morb
Mortal Wkly Rep, 2008. 57(39): p. 1073-6.
2. Marks, G., N. Crepaz, and R.S. Janssen, Estimating sexual
transmission of HIV from persons aware and unaware that they are
infected with the virus in the USA. AIDS, 2006. 20(10): p. 1447-50.
3. Marks, G., et al., Meta-analysis of high-risk sexual behavior in
persons aware and unaware they are infected with HIV in the United
States: implications for HIV prevention programs. J Acquir Immune
Defic Syndr, 2005. 39(4): p. 446-53.
4. Branson, B.M., et al., Revised recommendations for HIV testing of
adults, adolescents, and pregnant women in health-care settings.
MMWR Recomm Rep, 2006. 55(RR-14): p. 1-17; quiz CE1-4.
5. CDC, Technical Appendix II: HIVEcon: Additional notes and data on
model inputs and outputs. 2009. Available from: http://www.cdc.gov/ncidod/dq/laws_regs/part34/hivecon-appendix.pdf.
6. DHS, Yearbook of Immigration Statistics: 2007 Immigrants. Table
3: Persons Obtaining Legal Permanent Resident Status by Region and
Country of Birth: Fiscal Years 1998 to 2007. 2007. Available from:
http://www.dhs.gov/xlibrary/assets/statistics/yearbook/2007/table03d.xls.
7. UN, World Population Prospects: The 2006 Revision. Population
Division of the Department of Economic and Social Affairs of the
United Nations Secretariat., 2007. Available from: http://www.un.org/esa/population/publications/wpp2006/wpp2006.htm.
8. UNAIDS, 2007 AIDS Epidemic Update. WHO Library Cataloguing-in-
Publication Data: UNAIDS/07.27E/JC1322E, 2007. Available from:
http://data.unaids.org/pub/EPISlides/2007/2007_epiupdate_en.pdf.
9. DHS, Yearbook of Immigration Statistics: 2007 Immigrants. Table
8: Persons Obtaining Legal Permanent Resident Status by Gender, Age,
Marital Status, and Occupation: Fiscal Year 2007. 2007. Available
from: http://www.dhs.gov/xlibrary/assets/statistics/yearbook/2007/table08.xls.
10. Life expectancy of individuals on combination antiretroviral
therapy in high-income countries: a collaborative analysis of 14
cohort studies. Lancet, 2008. 372(9635): p. 293-9.
11. PDEII, et al., The New Americans: Economic, Demographic, and
Fiscal Effects of Immigration. Panel on the Demographic and Economic
Impacts of Immigration, National Research Council, Commission on
Behavioral and Social Sciences and Education and Behavioral and
Social Sciences and Education, ed. J.R. Smith and B. Edmonston.
1997: National Academies Press.
12. Borse, R.H. and M.I. Meltzer, Technical Appendix I: HIVEcon: A
model to estimate the economic costs of immigrants who are HIV-
positive. 2009. Available from: http://www.cdc.gov/ncidod/dq/laws_regs/part34/hivecon.html.
13. Schackman, B.R., et al., The lifetime cost of current human
immunodeficiency virus care in the United States. Med Care, 2006.
44(11): p. 990-7.
14. PAGAA, Guidelines for the Use of Antiretroviral Agents in HIV-1-
Infected Adults and Adolescents. DHHS Panel on Antiretroviral
Guidelines for Adults and Adolescents (PAGAA)--A Working Group of
the Office of AIDS Research Advisory Council (OARAC), 2008: p. 1-
139. Available from: http://aidsinfo.nih.gov/contentfiles/AdultandAdolescentGL.pdf.
15. USCIS, Interoffice memorandum: Consolidation of Policy Regarding
USCIS Form I-864, Affidavit of Support (AFM Update AD06-20). 2006.
Available from: http://www.uscis.gov/files/pressrelease/AffSuppAFM062706.pdf.
16. USDA, Public Law 104-193-Aug.22, 1996. 1996. Available from:
http://www.fns.usda.gov/snap/rules/Legislation/pdfs/PL_104-193.pdf.
17. USCIS, A quick guide to public charge and receipt to public
benefits. U.S. Department of Homeland Security, 1999. Available
from: http://www.uscis.gov/files/article/Public.pdf.
18. Pinkerton, S.D., How many sexually-acquired HIV infections in
the USA are due to acute-phase HIV transmission? AIDS, 2007. 21(12):
p. 1625-9.

[[Page 56561]]

19. CDC, HIV/AIDS Transmission Rates in the United States. CDC HIV/
AIDS Facts, 2008. Available from: http://www.cdc.gov/Hiv/topics/surveillance/resources/factsheets/pdf/transmission.pdf.
20. Lucas, J.W., D.J. Barr-Anderson, and R.S. Kington, Health
status, health insurance, and health care utilization patterns of
immigrant Black men. Am J Public Health, 2003. 93(10): p. 1740-7.
Available from: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=14534231.
21. Kenya, S., et al., Effects of immigration on selected health
risk behaviors of Black college students. J Am Coll Health, 2003.
52(3): p. 113-20. Available from: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=14992296.
22. Newcomb, M.D., et al., Acculturation, sexual risk taking, and
HIV health promotion among Latinas. Journal of Counseling
Psychology, 1998. 45: p. 454-467.
23. Hines, A.M. and R. Caetano, Alcohol and AIDS-related sexual
behavior among Hispanics: acculturation and gender differences. AIDS
Educ Prev, 1998. 10(6): p. 533-47. Available from: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=9883288.
24. Shedlin, M.G., C.U. Decena, and D. Oliver-Velez, Initial
acculturation and HIV risk among new Hispanic immigrants. J Natl Med
Assoc, 2005. 97(7 Suppl): p. 32S-37S. Available from: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=16080455.
25. Hoffman, S., et al., HIV and sexually transmitted infection risk
behaviors and beliefs among Black West Indian immigrants and US-born
Blacks. Am J Public Health, 2008. 98(11): p. 2042-50. Available
from: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=18309140.
26. McDonald, J.A., J. Manlove, and E.N. Ikramullah, Immigration
measures and reproductive health among Hispanic youth: findings from
the national longitudinal survey of youth, 1997-2003. J Adolesc
Health, 2009. 44(1): p. 14-24. Available from: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=19101454.
27. Lassetter, J.H. and L.C. Callister, The impact of migration on
the health of voluntary migrants in western societies. J Transcult
Nurs, 2009. 20(1): p. 93-104. Available from: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=18840884.
28. Shedlin, M.G., et al., Immigration and HIV/AIDS in the New York
Metropolitan Area. J Urban Health, 2006. 83(1): p. 43-58. Available
from: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=16736354.
29. Harawa, N.T., et al., HIV prevalence among foreign- and US-born
clients of public STD clinics. Am J Public Health, 2002. 92(12): p.
1958-63. Available from: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=12453816.
30. Marin, B.V., et al., Acculturation and gender differences in
sexual attitudes and behaviors: Hispanic vs non-Hispanic white
unmarried adults. Am J Public Health, 1993. 83(12): p. 1759-61.
Available from: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=8259813.
31. UNAIDS and IOM, Migration and AIDS. Int Migr, 1998. 36(4): p.
445-68. Available from: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=12295093.
32. CDC, HIV Incidence. 2008 (accessed May 25, 2009). Available
from: http://www.cdc.gov/hiv/topics/surveillance/incidence.htm.

VIII. Final Regulatory Flexibility Analysis

HHS/CDC has considered the final rule's effects on small entities,
as required by the Regulatory Flexibility Act (RFA) (5 U.S.C. 601 et
seq., Pub. L. 96-354) as amended by the Small Business Regulatory
Enforcement Fairness Act of 1996 (SBREFA) (Pub. L. 104-121). The RFA
establishes, as a principle of regulation, that agencies should tailor
regulatory and informational requirements to the size of the entities,
consistent with the objectives of a particular regulation and
applicable statutes.
The objective of this analysis was to compare the benefits and the
costs of a change in legislation that currently prohibits HIV-infected
immigrants from entering the United States. HHS/CDC carefully
considered several other alternatives, but they were either not
logistically feasible or they were not compatible with current U.S.
regulations. This analysis appears in the `alternatives' section.
HHS/CDC certifies the rule will not have a significant impact on a
substantial number of small entities as defined in the statute.

IX. Other Administrative Requirements

A. The Unfunded Mandates Reform Act

HHS/CDC evaluated the rule requirements for compliance with the
Unfunded Mandates Reform Act (UMRA) of 1995. This rule does not contain
Federal mandates under the regulatory provisions of Title II of the
UMRA for State, local, or Tribal Governments, nor for the private
sector. The rule's provisions will not affect small Governments.

B. Executive Order 13045: Protection of Children From Environmental
Health Risks and Safety Risks

Executive Order 13045 requires HHS/CDC to determine whether the
rule is economically significant. The Executive Order further requires
HHS to determine whether the rule would create an environmental health
or safety risk disproportionately affecting children. HHS/CDC has
determined that this rule does not create an environmental health or
safety risk.

C. Paperwork Reduction Act of 1995

The Paperwork Reduction Act applies to the data collection
requirements found in 42 CFR part 34. Currently, aliens determined to
have a communicable disease of public health significance may request a
waiver from DHS to enter the United States under sections 212(d)(3)(a)
and 212(g) of the INA (8 U.S.C. 1182(d)(3)(a) and 1182(g)). HHS/CDC has
approval from the Office of Management and Budget (OMB) under OMB
Control No. 0920-0006: Statements in Support of Application for Waiver
of Inadmissibility under the Immigration and Nationality Act
(expiration date December 31, 2011) to collect data pertaining to the
waiver; CDC Form 4.422-1b. HHS/CDC will discontinue the use of this
form, for a reduction of 67 burden hours for this approved data
collection.

D. Environmental Assessment

HHS has determined that provisions to amend 42 CFR part 34.2(b)
will not have a significant impact on the human environment.

E. Executive Order 13175: Consultation and Coordination With Indian
Tribal Governments

Executive Order 13175, entitled ``Consultation and Coordination
with Indian Tribal Governments'' (65 FR 67249, September 9, 2000),
requires agencies to develop an accountable process to ensure
``meaningful and timely input by tribal officials in the development of
regulatory policies that have tribal implications.'' The Executive
Order defines the phrase ``policies that have tribal implications'' to
include regulations and other policy statements or actions that have
``substantial direct effects on one or more Indian tribes, on the
relationship between the Federal government and Indian tribes, or on
the distribution of power and responsibilities between the Federal
government and Indian tribes.''

[[Page 56562]]

HHS/CDC has determined that provisions to amend 42 CFR Part 34 will
not have tribal implications.

F. Executive Order 12630: Governmental Actions and Interference With
Constitutionally Protected Property Rights

Under Executive Order 12630, if the contemplated rule would require
a Federal taking of private property, then a takings analysis is
required. Since the rule does not require a Federal taking of private
property, the provisions in the Executive Order are not applicable.

G. Executive Order 13132: Federalism

Under Executive Order 13132, if the rule would limit or preempt
State authorities, then a Federalism analysis is required. The agency
must consult with State and local officials to determine whether the
rule would have a substantial direct effect on State or local
Governments, as well as whether it would either preempt State law or
impose a substantial direct cost of compliance on them.
HHS/CDC has determined that this rule does not have sufficient
federalism implications to warrant the preparation of a federalism
summary impact statement.

H. Executive Order 13211: Energy Effects

Executive Order 13211 requires HHS/CDC to produce a statement of
energy effects if the rule is significant or economically significant
and likely to have a significant adverse effect on the supply,
distribution, or use of energy. HHS/CDC has determined that this rule
does not have that effect and that a statement of energy is not
required.

I. National Technology Transfer and Advancement Act

This act, 15 U.S.C. 272, requires the adoption of technical
standards developed or adopted by voluntary consensus standards bodies
in rules promulgated by HHS. No voluntary consensus standards are
applicable and feasible with regard to this rule.

J. Assessment of Federal Regulations and Policies on Families

Title 5 U.S.C.A. 601 (note) requires agencies to assess the impact
of a regulatory action to determine whether such an action would affect
family well-being. HHS/CDC has assessed the impact of this regulation
and has determined that it would not negatively affect family well-
being.

K. Executive Order 12988: Civil Justice Reform

HHS/CDC has reviewed this rule under Executive Order 12988, on
Civil Justice Reform and determines that this rule meets the standard
in the Executive Order.

L. Plain Language in Government Writing

Under 63 FR 31883 (June 10, 1998), Executive Departments and
Agencies are required to use plain language in all proposed and final
rules. HHS/CDC did not receive any comments seeking clarity on language
used in the NPRM. HHS/CDC has attempted to use plain language in
promulgating this Final Rule.

List of Subjects in 42 CFR Part 34

Aliens, Health care, Scope of examination, Passports and visas,
Public health.

0
For the reasons stated in the preamble, the Centers for Disease Control
and Prevention, within the U.S. Department of Health and Human
Services, is amending 42 CFR part 34 as follows:

PART 34--MEDICAL EXAMINATION OF ALIENS

0
1. The authority citation for Part 34 continues to read as follows:

Authority: 42 U.S.C. 252; 8 U.S.C. 1182 and 1222.

Sec. 34.2 [Amended]

0
2. Amend Sec. 34.2 by removing paragraph (b)(6) and redesignating
paragraphs (b)(7) through (10) as paragraphs (6) through (9)
respectively.

0
3. Amend Sec. 34.3 by revising paragraphs (b)(1)(i), (e)(1)
introductory text, (e)(2)(iv), (e)(5), and (e)(6) to read as follows:

Sec. 34.3 Scope of examinations.

* * * * *
(b) * * *
(1) * * *
(i) A general physical examination and medical history, evaluation
for tuberculosis, and serologic testing for syphilis.
* * * * *
(e) * * *
(1) As provided in paragraph (e)(2) of this section, a chest x-ray
examination and serologic testing for syphilis shall be required as
part of the examination of the following:
* * * * *
(2) * * *
(iv) Exceptions. Serologic testing for syphilis shall not be
required if the alien is under the age of 15, unless there is reason to
suspect infection with syphilis. An alien, regardless of age, in the
United States, who applies for adjustment of status to lawful permanent
resident shall not be required to have a chest x-ray examination unless
their tuberculin skin test, or an equivalent test for showing an immune
response to Mycobacterium tuberculosis antigens, is positive. HHS/CDC
may authorize exceptions to the requirement for a tuberculin skin test,
an equivalent test for showing an immune response to M. tuberculosis
antigens, or chest x-ray examination for good cause, upon application
approved by the Director.
* * * * *
(5) How and where performed. All chest x-ray images used in medical
examinations performed under the regulations to this part shall be
large enough to encompass the entire chest (approximately 14 x 17
inches; 35.6 x 32.2 cm).
(6) Chest x-ray, laboratory, and treatment reports. The chest
radiograph reading and serologic test results for syphilis shall be
included in the medical notification. When the medical examiner's
conclusions are based on a study of more than one chest x-ray image,
the medical notification shall include at least a summary statement of
findings of the earlier images, followed by a complete reading of the
last image, and dates and details of any laboratory tests and treatment
for tuberculosis.
* * * * *

Dated: October 22, 2009.
Kathleen Sebelius,
Secretary, Department of Health and Human Services.
[FR Doc. E9-26337 Filed 10-30-09; 8:45 am]
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