- These Guidelines provide guidance to jurisdictions that is necessarily generalist in nature. It is provided as overall guidance for the purposes of ensuring national consistency in the direction and manner of approach to the management of people with HIV who place others at risk. The Guidelines also provide a basis for inter-jurisdictional cooperation around these matters.
- It will be necessary that jurisdictions review and administer the Guidelines in a manner consistent with local legislative, administrative and service delivery arrangements. This will require that jurisdictions develop local protocols that take account of these variances and give effect to these Guidelines. Local protocols should nominate a public health authority to receive initial reports of cases from clinicians and other service providers; this may be the State or Territory Department of Health or the Chair of the HIV Advisory Panel. For the remainder of this document, this person will be referred to as the ‘nominated public health authority’.
- The framework for management of people with HIV who place others at risk includes the following levels:
- Level 1: Counselling, education and support
Management in the community by the client’s primary health care provider, with the assistance of specialist HIV case workers, as appropriate, without the formal involvement of the HIV Advisory Panel.
Level 2: Counselling, education and support under advice from HIV Advisory Panel or the Chief Health Officer or Equivalent
Management in the community under recommendations from the Chief Health Officer or equivalent and / or the 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.
Level 4: Detention and / or Isolation
Detention and / or isolation under a Detention Order and / or an Isolation Order or equivalent.
Level 5: Referral to Police
Referral to the Police under the Crimes Act or other relevant Act. Referral may be made at any stage under these Guidelines.
Each level is discussed in detail below.
- The issues covered by these Guidelines are complex. At all stages of their implementation, public health authorities and health care workers involved in the management of people who place others at risk of HIV infection are required to exercise considerable professional judgment based on the unique circumstances of each case.
- The application of the various levels of management under these Guidelines should be flexible and not necessarily linear, again responding to the circumstances of each case. This includes the possible referral of information to the Police at any stage in accordance with Level 5 of these Guidelines. Lower levels of intervention based on counselling, education and support in which the complex social, psychological and health care needs of the clients are addressed should always be preferred as opposed to intrusive or coercive measures unless those measures are deemed necessary.
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HIV Advisory Panel
- To administer the recommended regime each State and Territory will need to establish a standing HIV Advisory Panel. The function of the Panel is to provide expert advice to the Chief Health Officer or equivalent in the discharge of their responsibilities and, if requested, to provide advice and support to clinicians or other service providers involved in the care of a client whose behaviour places others at risk of HIV infection.
- ]The Panel should be chaired by a senior clinician with relevant expertise, such as a sexual health physician or a public health physician. Panel members could usefully include a HIV specialist, mental health service, HIV/AIDS community organisation with peer involvement, public health manager, legal policy advisor, and others co-opted as appropriate to an individual case.
- In addition to the permanent members of the Panel, the Chair may give consideration to involving others who may inform the Panel’s deliberations and who may be able to assist in the implementation of Panel recommendations.
- The State or Territory Department of Health should nominate an appropriate officer to observe Panel meetings. Additionally, the secretary of the Panel should be an officer nominated by the Department. That secretary will be responsible for maintaining Minutes for the Panel. Minutes of Panel meetings should be reviewed and approved by the Chair.
- The Panel should meet as needed or at least every four months in order to, at a minimum, receive a report from the Chair of the Panel on enquiries received by the Chair and advice provided in relation to clients being managed at Level 1 of the Guidelines, and to review the progress of clients being managed under the Guidelines at Level 2 or above. In circumstances where no enquiries have been received by the Chair and where no clients are being managed at Level 2 or above, it may be agreed that no meeting of the Panel is required.
- It is considered essential that the Panel meet at least at every four months to consider clients at Level 2 management or above as management at these levels entails close case management with or without an Order that is coercive. A regular meeting schedule, with additional meetings scheduled where necessary, allows for regular review by the Panel of the sufficiency and effectiveness of public health action under the Guidelines and, where appropriate, for change to be made to the Level at which a client is being managed under the Guidelines.
- Should a person to whom operation of the Guidelines might properly apply come to the notice of local clinicians or other service providers, contact should be made with the nominated public health authority to request a determination of a suitable course of action. Depending on the State or Territory local protocols, either the Chief Health Officer or equivalent or the chair of the HIV Advisory Panel may decide either to support the local clinician and service providers with advice alone (that is, to manage at Level 1 of the Guidelines) or to accept that the client should be managed under the Guidelines at Level 2 or above.
- When the Chief Health Officer or equivalent or the Chair of the HIV Advisory panel decides that an individual should be managed under the Guidelines at Level 2 or above, the HIV Advisory Panel should be convened to enable the individual’s case to be discussed by the Panel. The Panel should determine a course of follow up that may be short or longer term, and advise the Chief Health Officer or equivalent accordingly.
- In determining a course of follow up, the individual(s) who is/are to be responsible for implementation of any recommendations / determined actions and the timeframe for implementation will be specified. These will be recorded in the Minutes of the Panel meeting and / or minutes of Departmental meetings to assess progress of clients. Depending on the nature of the recommendations, the responsible individual(s) may be the local clinician, other providers, or the State or Territory Department of Health. The secretary to the Panel or the Chief Health Officer or equivalent will communicate all recommendations / determined actions to responsible individual(s).
- At all stages of management under the Guidelines, clear and appropriate documentation about the rationale for decisions made and the progress of implementation must be maintained.
- Case files should be kept according to the records management policies and standards of the State or Territory Department of Health, with consideration given to protecting the privacy of individual clients. Unique identifier codes should be used in place of names wherever possible to reduce the number of people needing to know the identity of clients. Consideration should be given to induction or training activities for administrative officers working with these files to ensure that they are aware of policies relating to the protection of medical information
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Maintenance, Discharge and Escalation under the Guidelines
- The cases of all individuals who are managed at Level 2 or above shall be considered at each meeting of the HIV Advisory Panel during the time in which they are under such management. At each such meeting, the Panel shall consider the circumstances of the case, action taken, other relevant information, and shall provide advice about whether the individual is to be maintained, discharged or escalated under the Guidelines.
- If the intervention decided is short term, the report back on the implementation of the Panel recommendations will be considered at the next meeting of the Panel. If the intervention is successful, the Chief Health Officer or equivalent may discharge the individual from management at Level 2 or above under the Guidelines in the interim and report this to the next meeting of the Panel.
- If the intervention decided is longer term, a report will be provided back to the Panel at its next meeting and the Panel will advise the Chief Health Officer or equivalent either to discharge the client from management at Level 2 or above under the Guidelines at that meeting or to continue with management at Level 2 or above under the Guidelines.
- In determining whether a client is to be discharged from management at Level 2 or above under the Guidelines, the Panel and the Chief Health Officer or equivalent will have regard to:
- whether actions recommended by the Panel have been implemented;
- the effectiveness of the implementation of the recommendations;
- continued information or evidence that the client is endangering others; and
- an assessment of the likelihood of the client endangering others.
- In making this determination, the Chief Health Officer or equivalent should consider management under the Guidelines at Level 2 or above to lapse in the absence of an ongoing assessment that the client is endangering or likely to endanger others. Discharge from management at Level 2 or above under the Guidelines constitutes an end to the Department and Panel’s involvement in the management of the client. Management will, of course, continue to occur via the local clinician / service provider.
- A client who is discharged may be re-admitted for management under the Guidelines at Level 2 or above at any time, as determined by the Chief Health Officer or equivalent, should the view be formed that the behaviours of the client would warrant such action.
- In circumstances where the Panel forms a view that the actions taken are not effectively or sufficiently protecting public health, or where there is evidence of increased risk of danger to others, the Panel may advise escalation of action in accordance with the Levels described below.