Guideline for the management of people with HIV whose behaviours may place others at risk of HIV

Guideline number: QH-GDL-367:2022

Effective date:  6 June 2022

Review date: 6 June 2025

Supersedes: Version 1

On this page:

1. Purpose of guideline
2. Scope of guideline
3. Background
4. Management of a person with HIV whose behaviours may place others at risk of HIV
5. Guideline case management
6. Level one: Case management by the clinician within their service
7. Level two: Case management by the clinician within their service, with department support, case reviews and recommendations
8. Level three: Case management under a magistrate's behavioural order, by the clinician within their service, with department support, case reviews and recommendations
9. Level four: Case management under a magistrate's detention order, by the clinician within their service, with department support, case reviews and recommendations
10. Related documents
11. Appendix 1: Summary of public sector health service clinicians’ roles
12. Appendix 2: Guideline case management framework
13. Appendix 3: Request for HIV Public Health Team advice or assistance
14. Appendix 4: Letter template for advising Communicable Diseases Branch of commencement of level one management
15. Appendix 5: Report template for providing Communicable Diseases Branch with a management update

1. Purpose of the guideline

The Public Health Act 2005 (Qld) provides a legislative framework to support the management of controlled notifiable conditions, which includes Human Immunodeficiency Virus (HIV). HIV is a virus that attacks the body’s immune system, and if not treated can lead to acquired immunodeficiency syndrome (AIDS). People with HIV who get effective HIV treatment can live long, healthy lives and prevent transmission of HIV to their sexual partners.

The Queensland Health Guideline for the management of people with HIV whose behaviours may place others at risk of HIV (the guideline) provides general information to assist public sector health service clinicians with the management of concerns relating to a person who may be placing others at risk of transmitting HIV to others. The guideline aligns with the National Guidelines for Managing HIV Transmission Risk Behaviours (2018). Each Australian state and territory have similar management processes in place.

In this guideline, ‘clinician’ refers to the medical practitioner providing the person’s HIV care.

The guideline offers a framework for the identification, investigation and case management of the small minority of persons with HIV whose behaviours may place others at risk of HIV. Case management as discussed in the guideline is not intended as a punitive measure, but rather is aimed at minimising HIV transmission risks through behaviour change, with preference given to strategies that are least restrictive, as these will generally be the most sustainable and effective in the long term.

Case management requires an approach which fosters the cooperation of the person with HIV. Management plans should respect and attempt to incorporate issues which may be relevant to a person or situation, including communication issues, cultural beliefs and practices, religion, gender, trauma history or power imbalance.

2. Scope of the guideline

The guideline is for all employees, contractors and consultants working within the Queensland public sector health system, comprised of Hospital and Health Services (HHSs) and the Queensland Department of Health (the department), and may be adopted to support best practice.

Private practitioners, general practitioners (GPs), visiting medical officers, HIV service providers and other relevant stakeholders may also choose to use or adapt the guideline for their own practices, however, importantly, the department is not responsible for any activities in the private sector based on use (or any adaption for use) of the guideline.

There is no legislative obligation to act under the guideline, and the guideline is not to be relied on as a substitute for individual clinical or legal advice.

2.1 Out of scope

There is a risk of HIV transmission through pregnancy and breastfeeding, but this is not within the scope of the guideline. Clinicians should consider recommending that women who are HIV positive and pregnant, or planning a pregnancy, seek advice from Children’s Health Queensland Infection Management and Prevention Service at Queensland Children’s Hospital who provide a statewide service.

3. Background

3.1 HIV is a manageable health condition

Although HIV is a lifelong infection with no cure to date, with treatment, it is considered a manageable chronic health condition. Treatment with anti-retroviral therapy (ART) reduces the level of virus and prevents HIV from replicating in the body, protects the immune system and enables the person to have a normal, or near-normal, life expectancy. Effective treatment dramatically reduces the risk of transmitting HIV to others (see section 4.4 of the guideline, HIV risk assessment and management).

3.2 HIV transmission and prevention

HIV can be transmitted via direct exposure to body fluids which contain the virus. Unprotected sexual contact and sharing of injecting equipment are the two main ways this may occur.

A person with HIV can reduce the risk of transmitting HIV to others by engaging in behaviours that minimise transmission, such as taking ART and maintaining an undetectable viral load, using condoms during sexual intercourse, and not sharing injecting equipment. The guideline accepts that "durable viral suppression (HIV RNA <200 copies/mL) eliminates the risk of sexual HIV transmission"  (ASHM 2020 U=U Guidance for Healthcare Professionals). Adherence to ART to maintain viral suppression is known as ‘treatment as prevention’ (TASP) or U=U (undetectable equals untransmissible). Use of HIV pre-exposure prophylaxis (PrEP) also reduces the risk of acquiring HIV.

3.3 The Queensland Health HIV Public Health Team

The HIV Public Health Team (HIVPHT) includes experienced HIV public health nurses and is part of the Communicable Diseases Branch, Department of Health, Brisbane, and HIV public health nurses based in Tropical Public Health Services, Cairns.

The HIVPHT:

• follows up laboratory and clinician notifications of all HIV cases diagnosed in Queensland in accordance with sections 70-75 of Public Health Act 2005 (Qld) (the Act) and seeks epidemiological and surveillance information
• provides advice to clinicians and people with HIV regarding referral pathways into HIV care and ongoing management
• assists clinicians with confidential HIV contact tracing aimed at preventing or minimising the spread of HIV
• provides advice on HIV-related public health issues
• provides advice to clinicians to assist them to investigate and manage people with HIV whose behaviours may place others at risk of HIV
• administers interjurisdictional cooperation recommended under the National Guidelines for Managing HIV Transmission Risk Behaviours (2018).

3.4 The HIV Advisory Panel

The HIV Advisory Panel (the panel) assists with monitoring and providing guidance on cases being managed according to the guideline. The panel consists of experts specialising in HIV, mental health, alcohol and other drugs, and public health, and includes an HIV positive peer representative. Other experts or advisors may be consulted to inform the panel’s discussions, assist in advising about the implementation of panel recommendations, and ensure that issues related to culturally and linguistically diverse or Aboriginal and Torres Strait Islander people and other factors such as sex work, drug use, intellectual and/or physical disability, and/or mental health are addressed. The panel is convened and chaired by the department’s Executive Director, Communicable Diseases Branch (ED, CDB), and cases are referred to the Chief Health Officer (CHO) where required for further advice or decisions. The panel meets regularly to review cases and advise the Chair, and to provide recommendations for case management.

The panel may recommend that a person should be managed under other Acts where appropriate, for example, the Mental Health Act 2016.

The panel, in conjunction with the person's treating team will take into consideration all available and relevant information for guideline management, including the following:

• the immediacy of the risk of HIV transmission to others
• the credibility of the information, including the basis on which conclusions have been drawn
• the outcome of any inquiry undertaken by the clinician and the HIVPHT
• the presence of a detectable HIV viral load, together with an assessment that risk behaviour is present and may be ongoing
• the adherence to treatment
• an assessment of the person’s capacity, competence, comorbidities and cultural factors that may impact behaviours
• the range and sufficiency of the clinician’s management of the case and involvement of appropriate services
• the degree to which, and reasons why, people at risk of acquiring HIV may be willingly engaging in, and consenting to, risk behaviours for HIV.

In all instances, clinicians will remain involved in the public health case management of the person.

4. Management of a person with HIV whose behaviours may place others at risk of HIV

4.1 Legislative framework

The Public Health Act 2005 (Qld) provides a legislative framework to support the management of controlled notifiable conditions, which includes HIV.

Under the Criminal Code Act 1899 (Qld) it is an offence to transmit a serious disease, however the department recommends assessment for supportive management under the guideline in the first instance if possible. Referral to the Queensland Police Service (QPS) may be mandated or recommended in some cases (refer to section 5.2 of the guideline). The enforcement of the Criminal Code Act 1899 by QPS is separate and distinct from public health case management under the guideline.

4.2. Guiding principles for case management

Case management under the guideline is a process of assessment, planning, facilitation and coordination of a person’s care, treatment, support, and advocacy, to enable them to minimise risk of HIV transmission. Consistent with the national guideline, is based on the following guiding principles:

• Apart from exceptional circumstances, testing for HIV should be conducted on a voluntary basis.
• People with HIV should not be isolated or excluded from social or sexual activities.
• Every individual has a responsibility to prevent themselves from acquiring HIV and preventing further transmission.
• The majority of people with HIV are motivated to avoid transmitting HIV to others, and the risk of transmission by most people with HIV is best managed through access to information, education, HIV treatment and other resources for the prevention of transmission of HIV.
• People who engage in HIV medical care and who demonstrate sustained undetectable viral load and adherence to ART can effectively minimise the risk of HIV transmission to others and are therefore less likely to require consideration for management under the guideline.
• Interventions should be proportionate to the risk presented, and be objective and without influence from stigma, discrimination, or prejudice.
• Every person with HIV should be provided with the following: effective clinical management and access to treatment; psychosocial support; counselling about prevention of transmission of HIV to others, including the role of treatment in reducing the risk of transmission; support to facilitate that all at risk contacts or partners are identified and tested for HIV; and linkage to relevant specialist, community and peer support services.
• Peer-based support and education can assist persons with HIV to adjust to their diagnosis, appropriately disclose their HIV status to others, and aid in understanding and preventing HIV transmission risks.
• Complex social, emotional, educational, cultural, intellectual and/or psychiatric factors can impact on the ability to maintain safe behaviours, but these factors do not necessarily mean the person is wilfully engaging in risk behaviours.
• Cultural considerations, sexual and gender diversity and all relevant factors should be considered throughout the process of implementing the guideline.
• Persons with HIV have the right to be managed in an equitable, non-discriminatory, culturally appropriate, and transparent manner, including having the right of review and appeal of decisions relevant to their management.

4.3 Identification and investigation of the concern

People with HIV whose behaviours may place others at risk of HIV require interventions which aim to support engagement in HIV treatment and care and promote health and lifelong behaviour changes to reduce HIV transmission risks.

A clinician may become aware that a person with HIV has placed, or may be placing, others at risk and, while not an exhaustive list, some examples for consideration include:

• Reports of HIV transmission risk behaviours by a person with HIV, for example, condomless anal and/or vaginal intercourse, or the sharing of used or contaminated injecting, tattooing or body piercing equipment. These reports should be considered in context with the person's behaviour, psychosocial state, and medical management.
• Evidence of possible HIV transmission, for example, when a person newly diagnosed with HIV identifies a person with HIV as their contact.
• A recently acquired sexually transmissible infection (STI) in a person with HIV. This requires careful examination of the persons HIV viral load and engagement in HIV care and associated issues, such as the STI, the site of infection and the HIV status of the person’s sexual partner/s.
• A statement of intent to place others at risk of HIV.

A review of relevant information is recommended which may include contact tracing information; previous reports of transmission risk; repeat STIs; disengagement or non-compliance with HIV care; recent HIV-related results indicating non-adherence with ART; and confidential liaison with other healthcare providers.

4.4 HIV risk assessment and management

The factors below provide guidance when assessing risk for HIV transmission and may be considered in partnership with other treating healthcare professionals and the person who is the subject of concern. Identifying potential risk minimisation interventions during the assessment will assist in case management planning.

The HIVPHT can provide further guidance regarding determining the risk of HIV transmission.

4.4.1 HIV status and management of HIV

Clinicians should confirm the HIV status and clarify the HIV management of the person who may be placing others at risk of HIV transmission.

HIV transmission risk varies according to the person’s:

• HIV medical management
• adherence to ART
• HIV viral load
• relevant risk reduction strategies.

Research has shown that people with HIV who take ART daily as prescribed and achieve and maintain sustained viral suppression, defined as an undetectable viral load or a viral load of less than 200 copies/mL, have effectively no risk of sexually transmitting the virus to a HIV-negative partner (National Guidelines for Managing HIV Transmission Risk Behaviours 2018).

4.4.2 The risk, context and setting associated with specific behaviours

Not all behaviours create the same degree of HIV transmission risk. The Australian National Guidelines on Post-Exposure Prophylaxis after Non-Occupational and Occupational Exposure to HIV provide guidance for assessing the likelihood of acquiring HIV with specific risk activities. Measures such as taking ART, maintaining an undetectable viral load, the use of condoms, not sharing needles or other equipment when injecting drugs, and engaging in HIV care, may represent a willingness to prevent transmission.

A person may be engaging in sex work or drug use, or may have social, cognitive, or mental health difficulties but this does not necessarily mean the person is placing others at risk.

A person not complying with measures to reduce the risk of HIV transmission may indicate the person is unable or unwilling to change the behaviour, which requires further investigation.

4.4.3 Willingness and ability to comply with HIV transmission risk reduction strategies

Clinicians should choose interventions to minimise HIV transmission risks based on the outcome of a comprehensive assessment.

Assessment of the following factors may assist to determine if a person requires support to reduce their HIV transmission risks behaviours:

• their understanding of the HIV diagnosis and knowledge of HIV
• their awareness of HIV transmission risk behaviours and strategies to reduce risk, including maintaining an undetectable viral load
• an identified need for education, counselling, or referral to relevant support services
• the presence of medical or mental health conditions, or substance use, which might affect their ability to make informed decisions and take appropriate actions
• availability of support systems including social, cultural, family and health
• cooperation with contact tracing discussions.

The following circumstances may indicate a person is unwilling or unable to comply with measures to reduce the risk of HIV transmission and may require further exploration:

• reluctance or refusal to participate in counselling
• failure to take appropriate precautions (for example, treatment non-adherence, refusal to use condoms)
• inability to maintain an undetectable HIV viral load
• lack of cooperation with contact tracing discussions
• refusal to disclose HIV status to sexual partners prior to unprotected sex and/or sharing of injecting equipment
• evidence that a person with a detectable viral load continues to engage in activities that pose a risk, for example, being diagnosed with an STI after receiving an HIV diagnosis
• substance use that may impair judgement
• mental health conditions, social disadvantage or domestic and family violence situations which may influence sound judgement or the person’s power to ensure risk minimisation behaviours.

The HIVPHT can provide further guidance to assist assessment and management of HIV transmission risk. Clinicians may also seek advice or liaise with their local sexual health service, Chief Executive, risk management committee or similar.

5. Guideline case management

5.1 Case management framework

Case management under this framework is maintained, escalated, de-escalated, or ceased based on a review by the clinician and/or the department where relevant. There are four levels of case management for a person whose behaviours may place others at risk of HIV:

• Level one: Case management by the clinician within their service
• Level two: Case management by the clinician within their service, with department support, case reviews and recommendations
• Level three: Case management under a magistrate's behavioural order, by the clinician within their service, with department support, case reviews and recommendations
• Level four: Case management under a magistrate's detention order, by the clinician within their service, with department support, case reviews and recommendations

The clinician may assign a case manager to assist with management of cases under the guideline.

In most cases, interventions implemented at levels one or two successfully assist the person to modify their behaviour and demonstrate they are willing and able to prevent placing others at risk of HIV transmission in future.

Irrespective of the level of management, all people with HIV should have access to HIV treatment, counselling, education and support. Clinicians should remain active in the care and support of the person under the case management framework and support the maintenance, escalation, de-escalation, or cessation of cases.

5.2 Queensland Police Service liaison

In exceptional circumstances, the department may liaise with QPS. In most cases the department would only consider referring a person to the QPS:

• if there were mandatory reporting obligations
• if all efforts to engage the person with case management under the guideline have been unsuccessful and further action may be required to minimise the person's HIV transmission risks to others
• where a person acts with clear intent to cause harm, or with serious disregard for the wellbeing of others.

The HIVPHT is available to discuss any concerns the clinician feels may warrant referral to the QPS.

5.3 Consent

Where possible and appropriate, obtain the person's consent for case discussions between relevant care providers and the panel. Any confidentiality or privacy concerns should be addressed by the panel. Where case management at any level of the guideline is recommended, the person will be advised and their cooperation with management will be sought.

In certain situations, cases may be discussed without consent. All cases will be managed in compliance with the privacy and confidentiality provisions of the Information Privacy Act 2009 (Qld); the Hospital and Health Boards Act 2011 (Qld);and the Act.

A person who has impaired capacity may require a substitute decision-maker to provide consent on their behalf in accordance with the provisions of the Guardianship and Administration Act 2000 (Qld).

5.4 Personal advocate

A person being managed under levels two to four of the case management framework should be offered the opportunity to have a personal advocate act on their behalf.

The personal advocate may represent the interests of the person by:

• supporting interactions with the panel
• communicating with the panel or the HIVPHT
• accompanying the person to meetings and appointments
• advocating for the protection of the person’s rights
• maintaining confidentiality.

6. Level one: Case management by the clinician within their service

Level one case management to minimise HIV transmission risk is undertaken by the clinician. Clinicians may seek assistance from the HIVPHT to implement level one case management.

The clinician may elect to commence level one case management based on the HIV transmission risks identified during their investigation.

It is recommended the clinician provide clinical management, access to treatment, counselling, education and support, and review the case after four months.

Ceasing or continuing case management may be based on:

• engagement in HIV management and level one interventions
• HIV transmission risk.

Level one interventions should be sufficient to support behaviour modification.

However, if the clinician assesses the person as being unwilling or unable to modify their HIV transmission risk behaviours, the clinician may seek assistance from the HIVPHT and/or refer the case to the ED, CDB for review and consideration by the panel with a view to escalating the level of case management. The clinician may seek assistance or refer the case using the Request for HIV Public Health Team advice or assistance form (see Appendix 3) or by writing a letter or email to the ED, CDB.

The HIV Advisory Panel will be advised of all cases commenced on level one of the guideline and may provide recommendations for management.

6.1 Clinician’s role

The following is a guide for level one case management.

At commencement of level one case management:

• advise the ED, CDB, that level one case management has been initiated (see letter template in Appendix 4)
• document the rationale for commencing case management
• inform the person that placing others at risk of HIV without the other person accepting the risk of infection may be an offence
• inform the person of the commencement of their case management under the guideline
• encourage HIV treatment as a preventative measure
• obtain the person's consent for case discussions between relevant care providers.

During level one case management:

• offer HIV treatment as prevention
• establish a case management plan with medical management and interventions to reduce risk of HIV transmission
• coordinate education, counselling, and referrals
• discuss and offer assistance with contact tracing
• offer monthly reviews to person and review case management
• document ongoing management of the case and the person's attendance and engagement at appointments
• provide updates every four months to the ED, CDB (see template in Appendix 5)
• cease or continue case management or refer for HIV Advisory Panel review.

Further information on the clinician’s role in level one case management is outlined below.

Note: if the person transfers their HIV care, advise the new clinician of their case management under the guideline and advise the ED, CDB of the transfer of care.

6.1.1 Treatment as prevention

A medical assessment should be initiated by the clinician as a priority so medical treatment and care can be discussed. This should include the personal health benefits of treatment and treatment as prevention.

6.1.2 Establish a case management plan

A case management plan may include:

• scheduled appointments for ongoing HIV clinical care
• assistance with contact tracing
• reviews and viral load testing to allow close assessment of the persons adherence to ART and HIV transmission risk
• interventions that will assist the person to minimise risk
• a referral for HIV peer support and referrals to other services as required
• regular review of case management progress and provision of feedback to the person
• assessment of ongoing risk of HIV transmission
• a formal review at four months to discuss ceasing or continuing management under the guideline or referral to the ED, CDB for consideration of management at higher levels.

6.1.3 Coordinate education, counselling and referrals

Education and counselling sessions should address transmission risk issues and include information such as:

• responsibility to prevent placing others at risk of HIV, including appropriate disclosure of HIV status
• HIV transmission risk factors
• HIV treatment as prevention
• Pre-Exposure Prophylaxis (PrEP) and Post-Exposure Prophylaxis (PEP)
• skills and support to minimise risk of transmission of HIV
• management of potential transmission risk situations
• reinforcement of safer sex and safer drug use practices.

Engaging the support of government and non-government service providers, for example, peer support organisations, specialist outpatients and private providers, may enhance a person’s case management.

6.1.4 Contact tracing

It is important that contact tracing is considered, discussed and supported during routine management of all patients with HIV. This is the process of identifying ‘at risk’ contacts of the person with HIV, and discretely and confidentially ensuring the contacts are aware of their possible exposure to HIV and are offered assistance to test and manage their HIV status.

Contact tracing may also be conducted by contact tracing officers appointed under the Act. This is a separate activity to the discussions undertaken in a clinical setting with the patient and any potential transmission ‘contacts’ they may have.

The HIVPHT or local Contact Tracing Support Officers attached to sexual health services within HHSs can provide further guidance and assistance with contact tracing if required.

Further guidance is also available in the Australasian Contact Tracing Guidelines (2021).

6.1.5 Review of level one case management

Monthly reviews should occur of the:

• efficacy of interventions initiated and completed to minimise risk of HIV transmission
• person’s ongoing HIV transmission risk.

Based on the outcome of the regular reviews, case management may be continued, ceased, or escalated.

Every four months the review should consider factors such as the benefits gained from continued support at level one and cessation or referral of case management. Clinicians should advise the ED, CDB, of the outcome of four monthly reviews (see letter template in Appendix 5).

If the clinician has concerns that the person’s HIV transmission risk is not being managed, the clinician should contact the HIVPHT for further guidance and/or refer the case to the ED, CDB for review and consideration by the panel with a view to escalating the level of case management. The clinician may refer the case using the Request for HIV Public Health Team advice or assistance form (see  Appendix 3) or by writing a letter or email to the ED, CDB. The panel will review the case and provide recommendations to the clinician regarding case management. The panel may recommend the clinician assign a case manager and facilitate referrals to specialist services for assessment, counselling, support and education.

6.2 HIV Public Health Team role

Clinicians may seek guidance from the HIVPHT for any/all aspects of level one case management.

6.3 Maintenance, escalation or de-escalation of level one case management

Level one case management may cease when:

• the interventions have been effective, and the person’s risks have been minimised
• there is no continued concern that the person is placing others at risk
• the person has acknowledged their commitment to behavioural changes in writing and detailed their plan to prevent placing others at risk in future
• the person’s behaviour and circumstances are such that escalation to level two (or above) case management is required.

If level one case management has ceased, the clinician is to:

• advise the person that level one management has ceased
• advise the ED, CDB
• continue routine monitoring, and ongoing support and care.

7. Level two: Case management by the clinician within their service, with department support, case reviews and recommendations.

If the clinician considers that a person may be placing others at risk of HIV and cannot be effectively managed at level one, the clinician may seek assistance from the HIVPHT and/or refer the case to the ED, CDB for management advice.

Level two case management is undertaken by the clinician, with department support, case reviews and recommendations. If level two case management is recommended by the panel, the department will advise the clinician, and the person will be provided with a letter seeking their engagement with the conditions of management.

The purpose of level two case management is to engage a person in a more intensive process to promote behaviour change and minimise HIV transmission risk. A person managed under level two should have access to all necessary HIV treatment, counselling, education and support, and be offered the opportunity to nominate a personal advocate.

The HIVPHT can provide guidance to the clinician throughout level two case management, and the panel will formally review the case and make recommendations regarding management at least every four months.

If at any time the clinician considers the person may be unwilling or unable to change their risk behaviour, the clinician may seek assistance from the HIVPHT and/or advise the ED, CDB.

7.1 Clinician’s role

The following is a guide for level two case management:

Continue to provide clinical management, access to treatment, counselling, education and support and other relevant level one case management interventions, and:

• refer the case to the ED, CDB for consideration of management under the guideline’s case management framework (see  Appendix 2)
• document the rationale for level two case management
• maintain interventions to reduce risk of HIV transmission
• implement recommendations from the panel
• facilitate referrals as recommended by the panel
• advise the person they may seek support from an advocate
• obtain the person's consent for case discussions between relevant care providers
• provide a report to the panel as requested
• if requested, participate in panel meetings to provide advice and information to the panel.

Further information on the clinician’s role in level two case management is outlined below.

7.1.1 Case referral

When referring a case to the ED, CDB, the clinician should provide a report of the case that includes:

• specific concerns
• details of the person’s HIV transmission risks
• interventions initiated and successfully completed by the clinic and other relevant care providers
• other relevant documentation
• a current assessment of the person’s medical management and HIV transmission risk.

The clinician may provide the report using the Request for HIV Public Health Team advice or assistance form (see Appendix 3) or by writing a letter or email to the ED, CDB.

7.1.2 Establish a case management plan for action and assign a case manager

A case management plan should prioritise interventions that will assist the person to minimise the risk of HIV transmission. Steps include:

• develop a case management plan based on a comprehensive assessment of medical and public health factors, which outlines an agreed course of action between the clinician and person, including timeframes and a schedule for follow-up consultations
• schedule at least monthly contact for support, education and review for the first four months and then as required. Negotiate suitable appointment times and provide a schedule of appointments to the person
• assign a case manager to assist with facilitating and coordinating the person’s care and monitoring.

7.1.3 Review of level two case management

Monthly reviews should occur to assess:

• the efficacy of interventions initiated and completed to minimise risk
• the person’s ongoing HIV transmission risk.

7.1.4 Clinician report for the HIV Advisory Panel

The clinician may be requested to provide the following information to the panel:

• date of last review and next appointment
• an assessment of the person’s engagement in HIV treatment and care
• results from recent HIV and STI tests
• a summary of assessments and management interventions
• an assessment of the person’s willingness and ability to prevent placing others at risk of HIV
• an assessment of the person’s HIV transmission risk
• any other information or concerns to be brought to the attention of the panel
• any recommendations for management.

If the clinician considers that the person may be continuing to place others at risk of HIV or is not cooperating fully with interventions to minimise risk, the clinician may seek assistance from the HIVPHT and/or advise the ED, CDB.

7.2 HIV Public Health Team role

The HIVPHT will:

• liaise with the referring clinician on matters such as: conducting a detailed assessment of the person and their HIV transmission risk; advising the person to consider seeking support from an advocate; the appointment of a nominated case manager; panel recommendations; contact tracing; engagement with interventions; assessments and agreements; and case management processes
• present case reports to the panel
• ensure the person's consent is obtained for case discussions between relevant care providers and the panel
• provide feedback to the clinician and/or person from the panel in compliance with confidentiality and privacy laws.

7.3 Maintenance, escalation, de-escalation or removal of level two case management

Upon review of the case, the panel will consider, in consultation with the clinician, whether to:

• continue level two case management
• escalate or de-escalate the level of case management
• cease case management under the guideline.

The panel will review the following:

• whether panel recommendations have been implemented
• effectiveness of the interventions, and the minimisation of HIV transmission risk
• assessment and management of continued HIV transmission risk or concerns
• a written statement of commitment from the person, and their strategies to prevent placing others at future risk of HIV transmission.

The panel will formally write to advise the person and their clinician when level two case management is no longer recommended or required.

8. Level three: Case management under a magistrate's behavioural order, by the clinician within their service, with department support, case reviews and recommendations.

Level three management under the guideline is case management under a court ordered ‘behavioural order’ [controlled notifiable conditions order] under the Act. Level three case management is undertaken by the clinician, with department support, case reviews and recommendations. The panel may recommend level three case management in the following circumstances:

• when a person on level two is unwilling or unable to change their behaviour, which may be placing others at risk of HIV

or

• when a person appears to be able, but unwilling, to change their behaviour, and refuses to engage in interventions to assist risk minimisation appropriate to levels one or two.

It is recommended the clinician contact the HIVPHT and their local legal unit for advice and assistance in the preparation, application and monitoring of a behavioural order. The person should also be advised by their clinician to consider obtaining legal advice or support.

Consider requesting that the application is heard in a closed court and for the identity of the person not to be published, nor any information to be published from which the person could be identified.

The clinician will remain actively involved in the application process and ongoing case management.

The Chief Executive or their delegate can apply for a behavioural order, or for an order to be extended, varied or revoked by a magistrate under the Act.

Behavioural restrictions or requirements are for the purposes of facilitating behaviour change and should be approached as supportive measures. They are not intended to be a penalty or punishment. Sections 126(1) and (2) of the Act describe what type of behaviour a behavioural order may cover, and the magistrate may also make the order subject to conditions that they consider appropriate (section 126(3) of the Act).

If a behavioural order is being considered, clear and comprehensive details of what is required under the behavioural order must be determined and written clearly in the behavioural order.

Behavioural order conditions may include requirements for the person to, for example:

• attend and engage in medical and other appointments
• undergo assessments and counselling
• refrain from specified behaviour
• refrain from visiting specific places
• be supervised and monitored.

The nominated health professional (usually the clinician or the assigned case manager) will supervise and monitor the person’s engagement and compliance with the behavioural order and provide a report to the panel.

Under level three case management, the panel will continue to review the case regularly and provide recommendations for management of the person.

The phases involved in obtaining a behavioural order under section 116 of the Act are:

Phase 1: The panel seeks approval from the Queensland Health Chief Executive (or delegate) to apply for a behavioural order

The Chief Executive can apply for a behavioural order under the Act to the magistrate.

The brief (or other memorandum) seeking approval to apply for a behavioural order must include the following documents (assistance should be sought from the HHS legal services and the HIVPHT with these documents):

• an affidavit from the clinician
• relevant forms
• a draft behavioural order for the magistrate to approve, detailing the conditions for the person to comply with.

Phase 2: Application to the magistrate for a behavioural order

Legal advice and assistance should be sought by both the clinician and the department to apply to the appropriate court for a behavioural order.

The Magistrates Court is contacted, usually by the HHS legal services, to arrange for the matter to be listed and heard before a magistrate. A time and location for the hearing is provided by the court.

All efforts to advise the person of this information should be made. However, if the person is unable to be located, and/or they do not attend the hearing, the order may still be sought and obtained under the Act.

When the matter is listed, the magistrate will consider all the information in the application and any supporting information, including all supporting affidavits. The magistrate may also want to hear in-person from clinicians or other departmental/HHS employees involved in the application.

The magistrate may:

• make the behavioural order in the same terms it was sought
• make the behavioural order in different terms than what was sought
• decline to make the behavioural order.

Phase 3: Serving the order

Some Queensland Health officers have been appointed as authorised persons under the Act and may serve behavioural orders made by the court on the person. As soon as practicable after the order is made an authorised person must:

• give a copy of the order to the person
• explain the terms and effect of the order to the person, including that it is an offence not to comply with the order
• give the person notice (in writing) about the right to appeal against the order and how to appeal.

Phase 4: Keeping documented records

When serving or enforcing the order, the authorised person must comprehensively document the details of their activities associated with serving the order and any action taken relevant to regulating compliance with the order.

Phase 5: Application to extend, vary or revoke a behavioural order

A behavioural order may be extended, varied or revoked under the Act. The panel will review the case and make recommendations at least every two months.

8.1 Clinician’s role

The following is a guide for level three case management:

Continue to provide clinical management, access to treatment, counselling, education and support and other relevant level one and level two case management interventions, and:

• in relation to the behavioural order:
  • provide details and relevant documentation to assist the preparation of a behavioural order application for the Chief Executive approval
  • provide an affidavit from a clinician detailing grounds for the behavioural order application, explaining the immediate risk to public health, and providing any other reason to support the application
  • assist in development of a draft behavioural order in as much detail as possible
  • seek legal advice and assistance with preparing the behavioural order, arranging a court hearing, obtaining the order and serving the order
  • initiate a comprehensive medical assessment; develop/adapt the case management plan to incorporate the behavioural order requirements; and monitor the person’s cooperation with the behavioural order and case management

• advise the person to consider seeking legal advice and support from an advocate
• if the clinician considers that an existing behavioural order should be extended, varied or revoked, liaise with the HIVPHT and/or ED, CDB and provide relevant details for the Chief Executive, who will determine whether to make this application to the court
• comprehensively document ongoing case management.

8.2 HIV Public Health Team role

The HIVPHT will:

• support the completion of a comprehensive assessment of the case for presentation to the panel
• inform the clinician of the panel’s recommendations
• liaise with the clinician to assign a case manager, if not already assigned, to plan, coordinate and monitor engagement in care and interventions to minimise risk
• provide guidance and assistance to the clinician as required or complete the requirements if relevant for all stages of preparation of and application for the behavioural order
• obtain department legal advice and assistance as required
• attempt to ensure the person is advised of their right to access peer support or advocacy, or to seek legal advice and assistance as required
• provide feedback from the panel to the clinician and/or the person in compliance with confidentiality and privacy laws
• provide guidance on case management, specific behavioural order requirements and panel recommendations
• monitor the person's engagement with the behavioural order
• discuss with clinicians and case managers any concerns regarding engagement in interventions or HIV transmission risk behaviours.

8.3 Maintenance, escalation or de-escalation of level three case management

In consultation with the clinician, the panel will review the case and consider whether to:

• continue level three case management
• escalate or de-escalate the level of case management
• cease case management under the guideline.

The panel may recommend new interventions, further assessments, or intensification of case management if a person is assessed as not cooperating with their case management or being unable to change their behaviour such that it places others at risk of HIV transmission.

If the interventions at level three fail to effect change which minimises the person’s HIV transmission risk to others, or if the person persistently refuses to cooperate, the panel may recommend management at level four.

9. Level four: Case management under a magistrate's detention order, by the clinician within their service, with department support, case reviews and recommendations.

Level four case management involves obtaining a detention order (controlled notifiable conditions order) made by a magistrate under the Act. A detention order allows for a person to be detained for up to 28 days for review or treatment.

Prior to seeking a detention order under the Act, legal advice should be sought by both the clinician and the department.

Consider requesting that the application is heard in a closed court and for the identity of the person not to be published, nor any information to be published from which the person could be identified.

While only required in rare and exceptional circumstances, level four case management may provide an opportunity to complete assessments, provide medical care and counselling and promote behaviour change. Options for detention may include detention at the person’s residence (although this may be difficult to monitor) or detention within a supervised environment, such as at a health facility.

Sections 130(1) and (3) of the Act describe what type of actions may be covered under a detention order and the magistrate may also make the order subject to conditions that they consider appropriate (section 130(2) of the Act).

Following completion of the period of detention, the person will likely be managed at level three or two of the guideline’s case management framework, or under another Act, depending on the outcome of assessments. However, if considered appropriate, an application may be made to the court to extend or vary the detention order under the Act.

An application for a behavioural order, to take effect after the period of detention, may also be submitted with the application for the detention order.

The phases involved in obtaining a detention order under the Act are:

Phase 1: The panel seeks approval from the Queensland Health Chief Executive to apply for a detention order

The Chief Executive can apply for a detention order under the Act to the magistrate.

The brief (or other memorandum) seeking approval to apply for a detention order must include the following documents (assistance may be sought from the HHS legal services and/or the HIVPHT with these documents):

• an affidavit from the clinician
• relevant forms
• a draft detention order for the magistrate to approve, comprehensively detailing the conditions for the person to comply with and the recommended duration and review of the order.

Phase 2: Application to the magistrate for a detention order

Legal advice and assistance should be sought by both the clinician and the department to apply to the appropriate court for a detention order.

The Magistrates Court is contacted, usually by the HHS legal services, to arrange for the matter to be listed and heard before a magistrate.

After a time and location of the hearing is provided by the court, the person should be advised of the date, time and location of the listing of the matter. However, if the person is unable to be located, and they do not attend court, the order may still be sought and obtained under the Act.

When the matter is listed, the magistrate will consider all the information in the application and any supporting information, including all supporting affidavits. The magistrate may also want to hear in-person from clinicians or other departmental/HHS employees involved in the application.

The magistrate may:

• make the detention order in the same terms it was sought
• make the detention order in different terms than what was sought
• refuse to make the detention order.

Phase 3: Serving the order

Some Queensland Health officers have been appointed as authorised persons under the Act and may serve detention orders made by the court on the person.

An authorised person must as soon as practicable after the order is made:

• give a copy of the order to the person
• explain the terms and effect of the order to the person, including the effect of section 132 of the Act (the person must remain at the place of detention for the period stated and undergo the stated medical examination or treatment)
• if not already at the place of detention, give the person an opportunity to voluntarily accompany the authorised person to the place of detention
• give the person notice (in writing) about the right of appeal against the order and how to appeal.

An authorised person may exercise powers given to them under the Act, which may include requesting police to attend.

Phase 4: Keeping documented records

When serving the order on the person, or enforcing the order, the authorised person must comprehensively document the details of their activities associated with serving the order and any action taken relevant to regulating compliance with the order. This may include the time and date of entry to the place for service of the order, and the time and date the order was served.

Phase 5: Details of medical examination and assessments must be explained

The clinician(s) undertaking the examination or assessment(s) of the person who is the subject of the detention order, must, if practicable:

• give an explanation to the person of the examination, assessment or treatment to be undertaken in a way likely to be readily understood by the person
• allow the person an opportunity to voluntarily submit to the examination, assessment or treatment.

Phase 6: Place of detention

A person may be detained at a place stated on the order. The place of detention may include, for example, the person’s residence or at a public sector health service.

Phase 7: Application for warrant for apprehension

An authorised person may apply to a magistrate for a warrant for apprehension of a person if the person absconds while under the order. Legal advice and assistance should be sought to apply to the court for a warrant for apprehension.

Phase 8: Application to extend, vary or revoke a detention order

A detention order may be extended only once for not more than 28 days or may be varied or revoked under the Act.

The panel will review the case and make recommendations.

Legal advice and assistance should be sought if the panel recommends the extension, variation or revocation of a detention order.

The relevant Magistrates Court registrar must be contacted to arrange for the matter to be listed and heard before a magistrate. The Chief Executive can apply for a detention order to be extended, varied or revoked by a magistrate under the Act.

9.1 Clinician’s role

The following is a guide for level four case management:

Continue to provide clinical management, access to treatment, counselling, education and support and other relevant case management interventions, and:

• in relation to the detention order:
  • identify suitable options for the place of detention
  • provide details and relevant documentation for the application for a detention order for the Chief Executive
  • provide an affidavit from a clinician detailing sufficient medical grounds for the detention order application, explaining the immediate risk to public health, and providing any other reason to support the application
  • assist in the development of a draft detention order form in as much detail as possible
  • seek legal advice and assistance with preparing the detention order, arranging a court hearing, obtaining the order and serving the order
  • ensure all activities associated with the detention order are comprehensively documented
• advise the person to consider seeking legal advice and support from an advocate
• provide encouragement and intensive support to the person throughout the period of detention
• undertake or organise the required examination and/or assessment of the person
• following the period of detention, continue to support the person and commence/continue case management as recommended by the panel, based on assessments during level four case management.

9.2 HIV Public Health Team role

The HIVPHT will:

• provide guidance and assistance to the clinician as required or complete the requirements if relevant for all stages of preparation of and application for the order
• assist in obtaining approval from the Chief Executive to apply for, extend, vary or revoke a detention order
• obtain department legal advice and assistance as required
• provide guidance to the clinician to assist with the completion of the required examinations and/or assessments of the person
• attempt to ensure the person is advised of their right to access peer support or advocacy, or to seek legal advice and assist as required.
• provide information for the panel’s consideration of the appropriate level and conditions of the person’s case management following the period of detention.
• provide feedback from the panel in compliance with confidentiality and privacy laws.

9.3 Maintenance, escalation or de-escalation of level four case management

Following completion of the period of detention of up to 28 days, the person will likely be managed:

• at level three or two of the guideline’s case management framework
• under another Act, depending on the outcome of assessments.

If considered appropriate, an application may be made to the court to extend or vary the detention order under the Act.

The panel may recommend new interventions based on the outcome of assessments completed during detention.

Related documents

• Australian Government Department of Health. (2018). National Guidelines for Managing HIV Transmission Risk Behaviours. Canberra: Australian Government Department of Health.
• Code of Conduct: For the Queensland Public Service – 1 January 2011. Public Service Commission, State of Queensland.
• Medical Board of Australia. (2014). Good Medical Practice: A Code of Conduct for Doctors in Australia. Canberra: Medical Board of Australia.
• Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine. (2016). Post-Exposure Prophylaxis after Non-Occupational and Occupational Exposure to HIV: Australian National Guidelines. 2nd ed. Sydney: Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine.
• Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine. Guide to Australian HIV Laws and Policies for Healthcare Professionals.

Appendix 1: Summary of public sector health service clinicians’ roles

This summary does not replace the comprehensive guideline and clinicians should read the full guideline before using the summary.

Appendix 2:  Guideline case management framework

This summary does not replace the comprehensive guideline and clinicians should read the full guideline before using the summary.

In exceptional circumstances risk management may require department liaison with the Queensland Police Service.

Appendix 3: Request for HIV Public Health Team advice or assistance form

Download the fillable request form (DOCX 74 kB) or the hard file request form (DOC 380 kB).

Appendix 4: Letter template for advising Communicable Diseases Branch of commencement of level one management

Download the letter template (DOCX 17 kB).

Appendix 5 Report template for providing Communicable Diseases Branch with a management update

Download the report template (DOC 36 kB).