In September 2019, the South Australian Code for the Case Management of Behaviours that Present a Risk for HIV Transmission (Code) was updated in line with the new National Guidelines for Managing HIV Transmission Risk Behaviours 2018.
The 2019 Code commits to managing clients while acknowledging the effect of undetectable HIV viral load.
Research has shown that people with HIV who take anti-retroviral therapies (ARTs) daily as prescribed, and achieve and maintain sustained viral suppression (defined as an undetectable HIV viral load or a HIV viral load of less than 200 copies/mL, measured at least quarterly or as recommended by their treating medical practitioner), have effectively no risk of sexually transmitting the virus to a HIV-negative partner and should therefore not be managed under the Code. Therefore, early commencement of therapy, high adherence to ARTs, sustained viral suppression, and retention in appropriate ongoing clinical care and treatment are the primary focus of management under the Code. Where a person is already being managed under the Code and is later able to demonstrate appropriate adherence to treatment and has a consistently undetectable HIV viral load, a graded withdrawal of staged public health measures should be undertaken, and the need for continued support assessed.
Thus, throughout the Code, where references are made to transmission risk behaviours, these should be read to imply that there is the presence of a detectable HIV viral load, together with evidence of risk behaviours.
The Code acknowledges the role of primary care in informing, educating and supporting people at the time of diagnosis in order to avert transmission risk. It is not intended to be used as a prevention education tool and, therefore, does not replace primary interventions by health and allied workers.
Management under the Code requires a consistent approach across all client groups regardless of gender, gender identity, disabilities, mental health diagnoses, sexual practices and orientation, work practices (including sex work), injecting-drug use, cultural background and/or religious beliefs, in order to maintain transparency, ensure fair treatment and to avoid any implication of stigma or discrimination. The Code aims to operate in a ‘non-judgemental’ way, acknowledging that a person with HIV may be placing others at risk for a range of reasons, including an incomplete knowledge or understanding of their condition and the risks that it presents, or complex personal issues or circumstances that might influence their behaviours or limit their options. Consequently, the Code states that its application may be considered an opportunity to work more intensively with an individual, so that they are provided greater support than what might otherwise be required to achieve safe and appropriate behaviours.
The Code states that (emphasis added):
‘Should a medical practitioner or any person involved in treating, caring for or counselling a person with HIV, form a reasonable belief that despite being given information and counselling … the person’s behaviours are presenting a risk to public health the person may refer the matter to the Chief Public Health Officer. The decision to refer a person is a matter of professional judgment for the medical practitioner, allied health worker or other clinician’.
The Code establishes 4 levels for managing the behaviours of a person who may be placing others at risk of HIV:
- Level 1 – the chief public health officer (CPHO) or staff of the Communicable Disease Control Branch (CDCB) receive information that a person with HIV is not taking reasonable steps or precautions to avoid placing others at risk. After a preliminary consideration and assessment by staff of the CDCB, there may be a decision to manage the person at the appropriate level of the process outlined in the Code.
- Level 2 – ongoing oversight by the director of the CDCB (as delegate of the CPHO) for the development and implementation of behaviour modification and case management strategies.
- Level 3 – the CPHO (or delegate) makes an order under s 74 or s 75 of the South Australian Public Health Act 2011 (SA) imposing counselling requirements and/or restrictions on the person’s activities on the advice of an advisory panel established under s 82.
- Level 4 – decision of the CPHO to isolate or detain the person under s 77 of the South Australian Public Health Act 2011 (SA) on the advice of an advisory panel established under s 82.
As a general principle, these levels would be applied in ascending order, commencing with level 1. However, if the CPHO, having considered the advice of the director of the CDCB and/or the advisory panel and having regard to the objects of the South Australia Public Health Act 2011 (SA) and specific principles (s 14), believes that more restrictive responses should be imposed earlier in the management process, then the CPHO will use the powers in the South Australian Public Health Act 2011 (SA) and make such orders as considered appropriate. Alternatively, a person who has been managed at a higher level of management may continue to receive intervention at a lower level should the CPHO or delegate consider it appropriate.
The Code is not without weight. Failure to comply with an order, requirement or direction carries a penalty of up to $25,000 under the relevant section of the South Australian Public Health Act 2011 (SA) (s 81). See a full copy of the Code, and a brief factsheet about the Code can be found.
