Canada: New guide offers practical advice to HIV nurses and clarifies professional obligations regarding HIV and the criminal law

A new guide which aims to address some of the realities and complexities faced by nurses and others who provide care to people living with HIV in Canada, is now available.

Covering everything from record keeping, confidentiality, viral load and safer sex to search warrants, subpoenas and testifying in court, it offers practical advice to HIV nurses and helps clarify their professional obligations regarding isues around HIV (non)disclosure and the criminal law.

Listen to lead author Marilou Gagnon, who gave an interview to CBC radio about the reasons for the guidance.

Developed by the Canadian Association of Nurses in AIDS Care (CANAC) in partnership with CATIE (Canadian AIDS Treatment Information Exchange), it was written in February 2013, four months after the release of the Supreme Court of Canada decisions in the cases of R. v. Mabior and R. v. D.C.

The guide is an extremely important resource at a very difficult and confusing time in Canada – not only for people living with HIV, but also those who work with, or advocate for them. Although the guide covers legal and scientific complexities around (non)disclosure that are specific to the Canadian context, it may also be helpful for HIV service providers in other jurisdictions. At the very least, this is a ‘best practice’ model for others to emulate.

This excerpt from the introduction provides a good overview of the content and tone of the guide, which can be ordered and/or downloaded from the CATIE website.

In the current Canadian legal context, it is important for nurses to maintain trust and therapeutic relationships with clients, to preserve a safe space for clients to talk about HIV disclosure issues, and to recognize that real-life experiences of HIV disclosure are far more complex than the idealized representation of disclosure expressed in the criminal law.† Furthermore, it is important for nurses to continue providing excellent nursing care across the HIV healthcare continuum from prevention through diagnosis and treatment to care and support.

Research papers, reports and grey literature all point to the challenges of providing nursing care given the current legal context. In these circumstances, it seems particularly prudent for nurses to clarify their role and responsibilities as members of the healthcare team and to have a clear understanding of their own obligations with respect to HIV non/disclosure.

It would certainly be helpful for nurses to use this guide as a tool to engage other members of the healthcare team and identify their respective roles and responsibilities.

This guide was primarily developed to support nurses who provide care to people living with HIV in Canada and offer some guidance on how to meet professional standards when dealing with non/disclosure in nursing practice. Guidance may not provide a definitive answer or indicate a correct course of action in a given circumstance. However, nurses should be aware that existing legal, ethical and professional frameworks can be relied upon to respond in a professionally sound manner to key questions and concerns.

There are areas of nursing practice that will remain uncertain, so it is important for nurses to work on a case-by-case basis in collaboration with the other members of the healthcare team, seek guidance when necessary, initiate referrals to legal services when required, engage in reflective practice, and be mindful of their professional obligations. Laws, professional standards and policies can change at any time. It is important for nurses to remain aware of any new developments because these will inform their own professional obligations.

Download the guide here.

What the REPEAL HIV Discrimination Act Means to Public Health | NASTAD Blog

By Oscar Mairena, Manager, Policy & Legislative Affairs and Viral Hepatitis This month, Congresswomen Barbara Lee (D-CA) and Ileana Ros-Lehtinen (R-FL) introduced bipartisan legislation, , the Repeal Existing Policies that Encourage or Allow Legal (REPEAL) HIV Discrimination Act.

Keeping Confidence: HIV and the criminal law from service provider perspectives (HJN, 2013) (3 of 4)

The Keeping Confidence one day conference was a free event to discuss findings from a report that we produced in conjunction with Birkbeck College. For more detailed information on the project please follow this link to the project description page: sigmaresearch.org.uk/projects/policy/project55/

Overview of updated 2013 BHIVA/BASHH position paper, ‘HIV transmission, the law and the work of the clinical team’

Dr Mary Poulton, Consultant and Clinical Head, Sexual Health and HIV, Kings College Hospital

Video produced by georgetownmedia.de

Mich. HIV data collection violates intent of statute, says lawmaker who helped create law

LANSING, MICH. – Michigan’s health department is violating the legislative intent of an HIV-related statute – and maybe the law itself – by indefinitely collecting information on people who test for HIV at federally funded clinics, says a former state lawmaker, who helped pass sweeping health reforms in the wake of the AIDS epidemic.

Germany: National AIDS Council releases powerful policy statement on HIV criminalisation

The German National AIDS Council – an independent advisory body of the Ministry of Health consisting of experts from the fields of research, medical care, public health services, ethics, law, social sciences, as well as people from the civil society – has produced a consensus statement on HIV criminalisation during consensual sex.

A press release issued yesterday by the Federal Ministry of Health states (unnofficial translation from German)

HIV infection has become a treatable chronic disease. In Germany, life expectancy with appropriate medical care is nearly normal. However, people with HIV still experience limitations, especially in everyday social life. They are often stigmatised and discriminated against in both the workplace and in the home environment. Criminal court judgments and their public perception play in a crucial role in this context.

The National AIDS Council points out that the following medical factors should be assessed in criminal proceedings: HIV is difficult infection to transmit compared to other sexually transmitted diseases. The transmissibility of HIV is primarily related to viral load. In the first weeks after infection this is particularly high, and can amount to several million viral copies per milliliter of blood. After a few weeks or months, however, the immune system, usually controls the infection. Once viral load drops the body can keep viral load low for months or years before medication needs to be taken. During this time, the risk of infection is much lower than in the early phase of infection. Once the immune system weakens, generally antiretroviral therapy commences. With effective treatment, the viral load falls below the detection limit (viral load less than 50 viral copies / ml blood). If viral replication is permanently suppressed completely, according to current medical knowledge, HIV is not sexually transmitted. The risk reduction of successful antiretroviral therapy is at least comparable to the correct use of condoms. It is assumed that a large proportion of HIV transmission takes place during the early stages of HIV infection, i.e. at a time, when those who are infected are not aware of their infection, because an HIV antibody test can only show infection after a few weeks.

Against this background, the National AIDS Council emphasises: A criminal examination of HIV exposure or transmission related to consensual sexual intercourse must be consistent with the medical facts. The decision whether or not the criminal liability of onward transmission can be assigned to the person with HIV cannot be made as a matter of routine. In fact, the determining factor are the circumstances of each individual case, especially the legitimate expectations of both sexual partners. In any case, in a short-term, consensual sexual encounter both partners are responsible for the application of protective measures, regardless of the knowledge or the acceptance of one’s own status and the status of the other person. Attributing either partner as perpetrator or victim is not appropriate.
Criminal proceedings regarding the transmission of HIV from consensual sexual intercourse do not contribute to HIV prevention. They can even be counterproductive in terms of the willingness of an individual to take an HIV test and in terms of open communication of sexual partners. In contrast, it is in the interest of the individual and society to increase willingness to take an HIV test.”

The full text of the statement (in German) can be found here.

UK: New research calls for better guidance for HIV service providers on criminal law, confidentiality and ethics

Yesterday saw the release of an important new UK study, Keeping Confidence: HIV and the criminal law from service provider perspectives, which explores how HIV criminalisation impacts those who deliver health and social care services for people with HIV.

The report’s lead author, Dr Catherine Dodds, from Sigma Research at the London School of Hygiene & Tropical Medicine, said: “Although HIV health and social care professionals expressed diverse views about their potential role in such cases, they gave a clear sense that criminal prosecutions for the transmission of HIV would not improve public health. Instead, it was most common to hear descriptions of such cases leading to increased stigma, reduced trust between service users and providers, and traumatic consequences for those involved in such cases.”

Study co-investigator, Matthew Weait, Professor of Law and Policy at Birkbeck, Univerisity of London, said: “This important and innovative research demonstrates both the problems that HIV criminalisation creates for clinical and social care providers and the need for solutions at both national and regional level. Care providers working in HIV and sexual health are concerned primarily with the health and wellbeing of their service users – which is of course as it should be; but there is also evidence that criminalisation is compromising their work. Increased awareness and understanding of, and inter-organisational communication about, legal issues is critical, and Keeping Confidence makes practical recommendations as to how that work might be taken forward for the benefit of prevention and support.”

Roger Pebody from aidsmap.com does an excellent job of summarising the study and its findings in this news report:

The study explored how criminal prosecutions for HIV transmission in England and Wales are handled by those who deliver clinical, psychosocial and community support for people with HIV. The report paints a picture of professionals grappling with the difficulties of communicating complex legal information in an appropriate way for each individual. They must weigh up competing concerns and responsibilities, including their own patient’s health and wellbeing, the health of unidentified sexual partners and the legal liability of their own organisation.

Read more at aidsmap.com

The report was launched in central London yesterday at a one-day meeting attended by around 70 HIV service providers, representatives of most of the UK’s community-based HIV organisations, and people living with HIV.

Following presentations of the report’s main findings, a panel consisting of a health adviser, and representatives of community-based organisaton and a people living with HIV discussed the implications for them.

Ceri Evans, Senior Health Adviser at the West London Centre for Sexual Health, Chelsea and Westminster Hospital, highlighted that there may not be a ‘best time’ to inform a newly diagnosed individual of their new legal obligations. Athough she agreed that the post-testing counselling session may not be ideal, she noted that since the criminal law potentially covers all sexually transmissable infections, including genital herpes, and there is usually only a single oppportunity to provide counselling following a new herpes diagnosis, that information about the law might need to be provided to some patients sooner rather than later.

Of note, the report’s fieldwork, involving 75 providers of HIV health and social care services in England and Wales, was undertaken in the latter half of 2012. Since then, the British HIV Association (BHIVA) and the British Association for Sexual Health and HIV (BASHH) have released an updated position statement on HIV Transmission, the Law and the Work of the Clinical Team which provides clinicians with information and guidance on managing many of the issues highglighted as problematic in the research. Lead author, Dr Mary Poulton, Consultant and Clinical Lad, Sexual Health and HIV, Kings College Hospital, London, outlined the main recommendations and provided case studies that illustrated how the decision-guiding algorithm regarding third-party disclosure might be particularly useful.

The rest of the meeting focused around discussing the report’s recommendations, which were as follows.

National recommendations

1. HIV service professionals will benefit from a single website or webpage that collates practical and accessible information about criminal prosecutions for the sexual transmission of HIV. It will need to be updated as new resources become available, and older ones are revised. New resources should be published as required in order to keep pace with clinical and scientific developments in the treatment of HIV that may impact on legal decision-making. The online resource can also identify the best sources of expert criminal legal advice where those are available.

2. A nation-wide programme of continuous professional development in the criminal law should be available to those who provide clinical and non-clinical HIV services. Topics covered should include: straightforward legal definitions and defence arguments, how and when to raise discussions about legal responsibilities, professional liability, communication skills development through the use of scenarios, and existing policy and practice models.

3. Key contacts with an interest in criminal prosecutions should be identified in each clinical and non-clinical HIV service organisation.This process should feed into the development of an updated list for the explicit use of disseminating information about information and training discussed in recommendations 1 and 2 above.The key contacts will also be utilised as the main organisational contact for the development and dissemination of resources to inform people with HIV about the law in this area.

Local recommendations

4. Existing professional guidance and associated documents should be discussed and adapted for local use. This will translate differently in specific settings, and it may lead to the development of local criminalisation policies or protocols, or values statements in some workplaces. At a minimum, such activities should strive for internal consistency on advice, facilitation and support.

5. Opportunities should be created for clinics and community-based organisations to exchange best practice as it relates to criminal prosecution for HIV transmission and to discuss where they agree and disagree on a conceptual level about the ethics of responsibility and public health in HIV prevention.

6. Alongside the development of local criminalisation protocols, all organisations will need to review their confidentiality policies, ensuring that they are accessible to service users, and compatible with internal agreements about criminalisation.

Whilst there was broad consenus regarding many of the recommendations, implementation will depend on various stakeholders collaborating, as well as sufficient funding.

Of note, currently only Australia has a website on HIV and the law aimed specifically at HIV healthcare professionals. The Australian Association of HIV Medicine (ASHM) online Guide to Australian HIV Laws and Policies for Healthcare Professionals covers civil, criminal and public health law, and also includes reference to national guidance on the Management of People with HIV who Place Others at Risk.

The entire day was filmed by the HIV Justice Network and video of the main presentations and final disussion outcomes will be available soon.

US: Journalist Todd Heywood discovers that Michigan health department have been secretly collecting HIV testing information for the past decade

Since 2003, the Michigan Department of Community Health has been secretly collecting the names, dates of birth, risk categories, and other demographic information of people submitting for confidential HIV testing at grant-funded locations throughout the state and storing them in a massive database, a months-long investigation by The American Independent has discovered.