Factors That Increase Risk For Hiv Infection
Sexually active but no history of being tested for HIV.
Use of shared drug equipment with a partner whose HIV status is unknown.
Unprotected anal or vaginal intercourse with a partner whose HIV status is unknown.
Multiple and/or anonymous sexual partnering.
For men, a history of sex with other men.
Diagnosis of other STI, hepatitis B or C.
Sexual activity, sharing of drug-use equipment, or receipt of blood or blood products for people originating from, or who have travelled to, regions where HIV is endemic.
Receipt of blood or blood products in Canada prior to November 1985.
Appendix D: Natural History Of Hiv Infection
Human immunodeficiency virus is a retrovirus that infects the cells of the immune system. It is transmitted via exposure to body fluids that contain lymphocytes or free infectious viral particles . The routes of infection are: unprotected sexual intercourse, sharing of injection-drug use equipment and from an HIV-infected mother to her unborn child. Although rare, HIV can also be transmitted through an occupational exposure such as a needlestick injury or other event where blood to blood exposure could occur. All blood and blood products used in Canadian healthcare settings now undergo extensive screening for HIV prior to use, so new infections related to their use have been virtually eliminated .
The virus can enter the body through unprotected mucous membranes where cells may become infected with HIV . The presence of a sexually transmitted infection can enhance HIV transmission because of lesions and/or an increased number of lymphocytes. Using a needle contaminated with HIV-infected blood deposits the virus directly into the blood system, where infection of lymphocytes will occur. Transmission from mother to child can take place in utero, during delivery through exposure to the mother’s blood or vaginal secretions, and through breast milk . Seroconversion occurs when an individual changes from being HIV antibody negative to HIV antibody positive.
Romeo And Juliet Exception
Named after Shakespeare’s young lovers, “Romeo and Juliet” exceptions are intended to prevent serious criminal charges against teenagers who engage in consensual sex with others close to their own age. In New York, there is a partial Romeo and Juliet exemption for consensual sex between a minor who is 15 or 16 and someone who is younger than 21. There is also a partial exception, a minor who is 11, 12, 13, or 14 years old, and a defendant who is younger than 17. This is a partial exception because, while these parties are protected from felony prosecution, they may nonetheless be charged for sexual misconduct which can incur up to one year in jail.2
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May The Department Of Public Health Notify Others Of My Hiv Status
Yes, New Hampshire law includes a general provision permitting the Commissioner of Public Health or his or her designee to do contact referral to notify persons who may have been infected with HIV. The law, however, prohibits the Commissioner or his or her designee from disclosing the identity of any HIV-positive individual . The States current practice is to offer assistance to HIV-positive individuals in notifying partners.
Section 70f: Hiv Test Informed Consent Disclosure Of Results Or Identity Of Subject Of Test
Section 70F. A facility, as defined in section 70E, physician or health care provider shall not test any person for the presence of the HIV antibody or antigen without first obtaining that person’s verbal informed consent disclose the results of such test to any person other than the subject of the test without first obtaining the subject’s written informed consent or identify the subject of such tests to any person without first obtaining the subject’s written informed consent. A written consent form shall state the purpose for which the information is being requested and shall be distinguished from written consent for the release of any other medical information.
No employer shall require HIV antibody or antigen tests as a condition for employment.
Whoever violates this section shall be considered to have violated section 2 of chapter 93A.
For the purpose of this section ”written informed consent” shall mean a written consent form for each requested release of the results of an individual’s HIV antibody or antigen test or for the release of medical records containing such information.
This section shall not apply to premortem and postmortem serological testing for purposes of donation under chapter 113A.
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What Happens When A Case Involves Suspected Child Abuse Or Maltreatment
Medical providers are required, by the NYS Social Services Law, to report situations involving suspected child abuse or maltreatment, including adult sexual activity with children age 12 and younger. Most often, by the time Health Department staff receive a report, the medical provider has already recognized and reported the abuse or maltreatment .
How Do I Obtain Patient Consent For Hiv Testing
Providers can obtain patient consent for HIV testing through any of the following ways:
Documented oral consent
- Providers must document oral notification in the patients medical record.
- In non-medical settings, note the conversation in the programs testing documentation for each client.
- Providers can document refusal as a means of documenting counseling without testing for billing or for their records.
General medical consent
- Patients can consent to an HIV test by signing a general consent for medical care.
- The general medical consent form must give the patient an opportunity to refuse HIV testing .
- For examples of acceptable language and model forms, see below or visit New York State Department of Health. Providers and agencies can develop their own consent forms without approval from New York State as long as the criteria above are met.
New York State HIV Testing Consent Forms
- Providers or agencies unable to use documented oral or general medical consent can use HIV testing consent forms created by The New York State Health Department in multiple languages. For copies of these forms, visit New York State Department of Health.
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Linkage To Prevention And Care
HIV testing is an important entry point for people into other services, such as HIV care, treatment, and prevention, as well as other services such as harm reduction and housing.
For people who test HIV positive, attempts should be made to ensure they are linked to, engaged in, and retained in HIV care and treatment, as well as to ensure they are linked to information and services related to prevention, to help avoid the onward transmission of HIV.
For people who test HIV negative, but may continue to be at risk of acquiring HIV, attempts should be made to ensure that they are linked to prevention services, such as pre-exposure prophylaxis and risk-reduction counselling, and repeat testing.
How Do Partner Services Specialists Approach Working With Minors
In New York State, minors are able to get certain sexual and reproductive health services, including STD/HIV testing and STD treatment, without their parent/guardian’s consent. In order to protect the minors’ confidentiality, Partner Services staff work directly with minors, rather than their parent/guardian. If a minor specifically indicates that they want their parent contacted, Partner Services staff will do so.
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Change Comes To New York
After decades of debate, in 2010 the New York State legislature voted overwhelmingly to modify the states legal framework for HIV testing the assembly voted 97 to 0, the senate 42 to 10. The result was a carefully crafted compromise. The statute required a mandatory offering of testing to people aged 13 to 64 years in hospitals, emergency departments, and primary care settings. Rapid HIV testing could be conducted using oral consent except in jails and prisons. Consent for testing could be integrated into general consent as long as a specific part of the form provided the clear option to decline the HIV test. It is of singular importance that once consent had been given it was to be considered durable and could be terminated only when a patient explicitly sought to withdraw it.
Although this statute finally permitted New York State to move forward, the long-fought controversy was not over. Patrick McGovern, the chief executive officer of Harlem United, declared in 2010,
New Yorks debate on HIV testing . . . has been passionate and sometimes contentious . . . while this legislation falls short on a true opt out approach, the required offer of HIV testing in all primary care settings foretells an end to the current practice of segregated and stigmatized HIV testing.
Gay Mens Health Crisis, by contrast, underscored that it had protected written informed consent under challenging political circumstances:
For Carrie, a new battle
Catie Resources For Service Providers
References
Harrigan M.
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Does New Hampshire Have A Law Governing Consent For Hiv Testing
Yes, New Hampshire has a statute mandating consent for an HIV test, except in certain cases which are enumerated later. A physician, licensed nurse practitioner, employee of a health care facility, or employee of a blood bank, may administer an HIV test when the patient has provided his/her consent .
Planning For Hiv Testing
Providing extended counselling, while preferred, may act as a barrier to testing for both the care provider and the testing client. The considerable resources and time required to conduct extensive risk assessments and pre- and post-test counselling have limited the ability of care providers to offer HIV testing. Behaviour-based risk assessments may also deter individuals from accessing testing, as such practices may involve revealing sensitive personal information. Both providers and clients may feel uncomfortable discussing such topics and, consequently, may avoid testing. The result is “missed opportunities” to diagnose those unaware of their HIV infection and link them with the treatment, care and support they need.
Providing sufficient information and supportive resources in conjunction with HIV testing does not necessarily require expertise in counselling or therapy. The level of support required in any given testing situation is highly dependent on the type of test and the testing client. While some clients may require comprehensive counselling, others may only need an abbreviated discussion supplemented with information resources such as brochures or websites.
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New Yorknine Years Of Contention
In the face of such opposition, legislators in New York State tried repeatedly from 2006 to 2010 to address the restrictive legal constraints under which HIV testing could occur. In this period, 169 HIV-related bills were introduced to the state legislature, 12 of which explicitly addressed informed consent.
What unfolded was a morally charged debate regarding whether written informed consent impeded what all agreed was crucial: that individuals who were infected but unaware be able to learn their HIV status. The New York State Medical Society, which exemplified one side of this argument, wrote a letter to Assemblywoman Nettie Myerson, a leading proponent of routinizing HIV testing:
For over 20 years, physicians and other health care personnel have not been allowed to offer HIV testing as part of the standard tests that are offered patients.
Paradoxically, the very exceptionalism that was designed to protect those at risk had stigmatized the test for the disease.
There is absolutely no scientific evidence that the statutory requirements of written informed consent and counseling pose an actual barrier to testing.
Some have cited written consent as a barrier to testing. . . . Such claims have proven baseless and have not been empirically documented in any major peer reviewed academic journal.
Terms And Technologies Used In Hiv Testing
This section provides detailed definitions and descriptions of the terms and technologies used in HIV testing.
4.2.1 Algorithms
Algorithms for HIV testing have been developed to ensure optimal sensitivity while preserving specificity by confirming reactive results as antibody-positive. The test sequence starts with the most sensitive screening test to identify all those with antibodies. A confirmatory assay is then performed only on the samples that tested reactive/positive on the initial screening test. This ensures that the screen test reaction is due to detection of HIV antibodies rather than a non-specific reaction. In the case of indeterminate or inconclusive results, additional supplementary testing may be necessary to determine if someone is infected with HIV. Each laboratory develops and validates its own algorithm to ensure that it provides the most accurate results possible. The positive predictive value and negative predictive value of a validated algorithm are close to 100%.
A typical laboratory testing algorithm follows:
Figure 3: Laboratory Testing Algorithm
A typical laboratory testing algorithm starts by screening with an enzyme immune assay test. If the EIA is non-reactive, then no HIV infection is present and no further testing is done.
If the initial EIA is reactive, then the EIA test should be repeated two additional times. If neither of the additional EIA tests is reactive, then the test is considered non-reactive, with no evidence of HIV infection.
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Other Factors Influencing Hiv Transmission Risk
Within each route of transmission, estimates of the risk of transmission vary widely, likely due to the role of behavioural and biological co-factors. Viral load appears to be an important predictor of transmission, regardless of route of transmission. However, the evidence indicates that viral load is not the only determinant, and other co-factors, such as the presence of co-infections, play a role in increasing or decreasing the risk of transmission.
Viral Load
The strongest predictor of sexual transmission of HIV is plasma viral load . A dose-response relationship has been observed, where each ten-fold increase in plasma VL resulted in an increased relative risk of transmission of 2.5 to 2.9 per sexual contact. The concentration of HIV in genital secretions also plays a major role in sexual transmission. While there is a strong correlation between HIV concentrations in plasma and in genital secretions, some studies have found genital tract HIV shedding in 20% to 30% of men and women without detectable plasma viral load. Much of what is known about the impact of viral load on the sexual transmission of HIV is derived from studies of heterosexual populations. Very little is known about the relationship between HIV viral load and rate of transmission through anal intercourse.
Co-infections
Circumcision
Do Health Care Professionals Ever Have An Obligation To Warn A Third Party About A Clients Hiv Status
A counselor or physician may learn that a client is engaging in unsafe sex without having disclosed his or her HIV-positive status to the partner. Many people have asked whether there is a legal basis to breach client or patient confidentiality under these circumstances. It is the AIDS Law Projects view that there is no clear justification for such a breach of confidentiality under New Hampshire law. Providers and consumers alike, however, should be aware that the case law in this area is still developing and remains unresolved. For a legal opinion on how to handle a particular situation, a professional should consult with a supervisor or lawyer.
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State Of Maryland Law And Consent For Hiv Testing
The State of Maryland law regarding consent requirements for HIV testing changed on July 1, 2008. The requirement to use the States informed consent document for HIV testing performed in a health care facility was revised. Use of the State form is not required if there is documentation in the medical record that informed consent was obtained from the individual who was asked to have HIV testing. Documentation in the medical record must state that the individual tested received pre and post-test counseling and was informed she/he had the right to refuse HIV testing without penalty.
The State HIV testing form is still available to clinicians and researchers. The Organization has determined that researchers who conduct research that involves HIV testing have the following two options to meet State requirements for documentation of testing.
Questions regarding the requirements for documentation of HIV testing should be directed to the Office of Human Subjects Research.
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What Happens If The Result Is Negative
If a standard test reveals that the individual is HIV negative, the provider explains the result, ensures the person understands the result, and discusses any other questions about HIV testing, transmission, or prevention. They may also discuss the need for further safer sex or harm reduction education or other services, provide referral to other community services as appropriate, and discuss opportunities for other testing, such as sexually transmitted infections or hepatitis C, if appropriate.
If a rapid point-of-care test is non-reactive, the person is given the result and post-test counselling as appropriate to their individual needs. This whole process can be completed in one 20-minute visit .
People who test negative but are in the window period, may be advised to test again at an appropriate time to ensure the result is accurate. For those who test HIV negative, but are at continuing high risk for infection, efforts should be made to actively ensure that they are linked to and engaged in enhanced prevention services and risk-reduction counselling. They should also be encouraged to repeat testing as necessary.
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