Managing HIV transmission risk behaviours #
A multidisciplinary, community-based response has reduced the rate of transmission of HIV in Australia. HIV prevalence in Australia is as low, or lower, than in most comparable countries. In 2021, Australia had an estimated national HIV prevalence of 0.14%, which is considered to be low when compared with other high-income countries (J King et al., HIV, viral hepatitis and sexually transmissible infections in Australia: Annual Surveillance Report 2022 (Report, 2022)). Estimated HIV prevalence in several neighbouring countries is substantially higher than that in Australia.
If not appropriately conducted, the public health management of individuals suspected of putting others at risk of HIV and the loss of public and community trust threaten to undermine voluntary cooperation with public health aims and their success. Patient management must be expert and responsive to the needs of both the person with HIV and any possible sexual contacts. Moreover, it must be supportive of individuals so that they may be provided with opportunities to successfully connect with care and understand their responsibilities to prevent the risk of HIV transmission. The duty of clinicians to warn and the responsibility of HIV patients to take reasonable precautions against the risk of HIV transmission is outlined in Public health offences – reasonable precautions and duty to warn.
In general, healthcare practitioners should not hesitate to contact their health department for support and guidance from their state expert panel for advice regarding those who place others at risk of HIV.
Healthcare practitioners will manage challenging and difficult situations, and must understand the dynamics of each individual therapeutic relationship and their capacity to exercise expert clinical judgement.
The following is from Scammell and Ward (see State-based information resources for full citation):
‘Each state in Australia, either through statute alone or a combination of statute and departmental policy, has mechanisms in place to manage [people living with HIV] who are at risk of [transmitting HIV to] others. These mechanisms have been designed to facilitate behavioural change of individuals identified as posing a risk of passing on HIV to others. As such, these public health management tools represent a more individualised and coercive aspect of the public health response to HIV transmission than the health promotion and education activities that are generally directed towards at-risk population groups in society’.
It is important to note that the number of individuals for whom these mechanisms apply at any one time is small. The overwhelming majority of people living with HIV in Australia ensure that transmission of HIV to others does not occur, through a variety of prevention practices. However, owing to a range of psychosocial and structural factors, there are some people who engage in behaviour that could or does place others at risk of HIV. Public health mechanisms may be enforced at the point where the public health system deems there is a risk to the wider population as a result of the actions or inaction of an HIV-positive patient. Sometimes responses may be considered supportive, and sometimes they are clearly coercive.
The National Guidelines for Managing HIV Transmission Risk Behaviours 2018 are intended to create a consistent and stepwise approach across all Australian states and territories. States and territories have their own jurisdictionally specific laws, guidelines and policies.
The National Guidelines #
The National Guidelines for Managing HIV Transmission Risk Behaviours 2018 outline 4 levels of intervention. They are underpinned by the principle that for people with HIV, who place others at risk, a variety of increasingly interventionist strategies may be required. Preference is given to strategies that are least restrictive, as these will generally be the most sustainable and effective in the long term.
The 4 recommended levels of intervention are:
Level 1 – Counselling, education and support #
management in the community by the person’s healthcare team with the assistance of specialist HIV case workers, as appropriate, and with advice from the nominated public health HIV contact but no formal involvement of the HIV Advisory Panel
Level 2 – Counselling, education and support under advice from the designated state or territory authority and formal involvement of HIV Advisory Panel #
management in the community under the recommendations from the designated state or territory authority on advice from HIV Advisory Panel but without a behavioural order (This may include a formal letter of warning.)
Level 3 – Management under behavioural order #
management under a behavioural order or equivalent (The order may include various measures from Level 1 and/or 2, thereby making them mandatory.)
Level 4 – Detention and/or isolation #
Detention and/or isolation under a detention order and/or an isolation order or equivalent The individual state guidelines and procedures are set out at State-based information in the following sections.
