Guideline for the management of people living with HIV whose behaviours have placed or may place others at risk of HIV

Guideline number: QH-GDL-367

Effective date:  27 March 2026

Review date: 27 March 2029

Supersedes: Version 2.0

On this page:

1. Purpose of guideline
2. Scope of guideline
3. Background
4. Management of a person living with HIV whose behaviours have or 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. Clinician role in case management for transient/unlocatable persons
11. Related documents
12. Appendix 1: Summary of public sector health service clinicians’ roles
13. Appendix 2:  Guideline case management framework
14. Appendix 3: Letter template for advising the HPHT, NQHT or Chair of the HIV Advisory Panel of commencement of level one management
15. Appendix 4 Report template for providing the Chair of the HIV Advisory Panel with a management update
16. Review
17. Business Area Contact
18. Approval and Implementation
19. Version Control
20. Change Table

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 infection with Human Immunodeficiency Virus (HIV).

The Queensland Health Guideline for the management of people living with HIV whose behaviours have placed or may place others at risk of HIV (the guideline) provides general information and guidance to assist public sector health service clinicians with the management of concerns relating to a person who;

• may be placing others at risk of HIV;
• has previously placed others at risk of HIV; and/or
• has been confirmed to have knowingly transmitted HIV.

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:

‘Service’ refers to a clinical service (e.g. clinic, GP service or outpatient department and the healthcare staff working there) where a person with HIV accesses their HIV medical care. The service may include more than one location, however, with public sector health services, these are usually within the same Hospital and Health Service (HHS).

‘Clinician’ refers to an accredited S100 Prescriber (medical and nursing) providing the person’s HIV care. Noting that other members of the person’s care team e.g. peer support workers and psychologists, play a significant role in minimising HIV transmission risk.

The guideline offers a framework for the identification, investigation and case management of the small minority of persons living with HIV whose behaviours have placed or 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 supporting individuals to change behaviour, with preference given to strategies that are least restrictive, as these will generally be the most sustainable and effective in the long term.

2. Scope of the guideline

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

Private practitioners, general practitioners (GPs), private S100 Nurse Practitioners, 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 an infectious diseases and/or sexual health specialist.

3. Background

3.1 HIV is a manageable health condition

HIV is a virus that attacks the body’s immune system, and if not treated can lead to acquired immunodeficiency syndrome (AIDS). 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 circulating quantity of virus and limits HIV replication 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 via sexual transmission and mother to child transmission (see Section 4.4 of the guideline, HIV risk assessment and management). People living with HIV who receive effective HIV treatment can live long, healthy lives and prevent transmission of HIV to their sexual partners.

3.2 HIV transmission and prevention

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

A person living 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 post-exposure prophylaxis (PEP) and pre-exposure prophylaxis (PrEP) also reduces the risk of acquiring HIV.

Research has shown that people living 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).

3.3 The HIV Public Health Team (HPHT) and North Queensland HIV Team (NQHT)

The experienced HIV public health nurses in the HIV Public Health Team (HPHT) sit in the Blood Borne Virus and Sexually Transmissible Infections Public Health Nursing Team in the Communicable Diseases Branch, located in Brisbane. The North Queensland HIV Team (NQHT) comprises experienced HIV public health nurses based in the Cairns Public Health Unit.  The teams manage HIV notifications and provide advice on HIV-related public health matters; HPHT serves areas in Queensland south of Mackay and the NQHT serves areas from Mackay to the Torres Strait.

Anyone, including a clinician, healthcare professional, Queensland Police Service (QPS) employee, member of the public, educational establishment staff and a workplace owner may seek advice from the HPHT or NQHT:

HIV Public Health Team 07 3328 9797 HIV_PH_Team@health.qld.gov.au

North Queensland HIV Team 07 4226 5555 NQHT@health.qld.gov.au

3.4 The HIV Advisory Panel

The HIV Advisory Panel (the panel) is not a panel established under legislation. However, the panel assists with monitoring and providing guidance to clinicians and other members of a person’s care team e.g. peer support worker and psychologist, on cases being managed according to the guideline.

The panel consists of experts specialising in HIV, mental health, alcohol and other drugs, public health, and First Nations people’s 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 people and other factors such as sex work, drug use, intellectual and/or physical disability, and/or mental health are considered.

The panel is convened and chaired by a Senior Medical Officer in the department’s Communicable Diseases Branch, 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 to provide recommendations to clinicians for case management.

The panel may recommend that a person is assessed for management under other Acts where appropriate, for example, the Mental Health Act 2016 (Qld).

The panel, in conjunction with the person's clinician or relevant care team member, will take into consideration all available and relevant information for case management under the guideline, including the following:

• the immediacy of the risk of HIV transmission to others;
• the credibility of the information about behaviours, including the basis on which conclusions have been drawn;
• the outcome of any inquiry undertaken by the clinician and the HPHT/NQHT;
• the presence of a detectable HIV viral load, together with an assessment of risk behaviour;
• 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; and
• 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.

3.5 Inter-jurisdictional cooperation

The panel will participate in interjurisdictional cooperation as required, taking into consideration the recommendations under the National Guidelines for Managing HIV Transmission Risk Behaviours (2018).

Where the panel has formed an opinion that a person under level two management (see Section 7 of the guideline), has travelled, or is planning extended travel or relocation to another jurisdiction, the Chair of the panel should consider notifying the relevant jurisdictional CHO, or relevant delegate, about the person. If the person is being managed at level three (see Section 8 of the guideline) or level four (see Section 9 of the guideline), then the case must be referred to the relevant jurisdictional CHO, or relevant delegate and the Queensland Health chief executive or their delegate must make the referral. All necessary case information, including information that allows the identification of the person, to enable effective public health follow-up should be provided with the referral. However, importantly, legislative confidentiality and privacy obligations must be complied with, and approval for disclosure of confidential information must first be obtained by the relevant person under the relevant legislation.

4. Management of a person living with HIV whose behaviours have placed or may place others at risk of HIV

4.1 Legislative framework

The Public Health Act 2005 provides a legislative framework to support the management of controlled notifiable conditions, which includes HIV. Under section 143 of the Public Health Act 2005 (1) A person must not recklessly put someone else at risk of contracting a controlled notifiable condition (2) A person must not recklessly transmit a controlled notifiable condition to someone else.

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. However, referral to the 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 the 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, it is based on the following guiding principles:

• Apart from exceptional circumstances, testing for HIV should be conducted on a voluntary basis.
• People living 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 living with HIV are motivated to avoid transmitting HIV to others. The risk of transmission by most people living with HIV is best managed through access to information, education, HIV supportive care and treatment and other resources for the prevention of transmission of HIV.
• People who engage in HIV clinical 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 living 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. Ongoing education, contact tracing, counselling about risks and offers of support as required as part of routine monitoring and care.
• 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 safe, and transparent manner, including having the right of review and appeal of decisions relevant to their management.
• Human rights will be considered in all decisions made.
• Every person has a right to choose not to take ART or engage in care, however, every effort should be made to provide people living with HIV the opportunity to receive contemporary education and support about the benefits of treatment and care and their public health responsibilities not to place others at risk of HIV.

Case management requires an approach which fosters the cooperation of the person living 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.

4.3 Identification and investigation of the concern

People living with HIV whose behaviours have placed, or 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 or other person may become aware that a person living 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 living 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 clinical management.
• Evidence of possible HIV transmission, for example, when a person newly diagnosed with HIV identifies a person living with HIV as their contact.
• A recently acquired sexually transmissible infection (STI) in a person living with HIV without a supressed viral load. 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 and a non-supressed viral load; 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 HPHT/NQHT 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 persons:

• HIV clinical management;
• adherence to ART;
• HIV viral load; and
• relevant risk reduction strategies.

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 of HIV transmission.

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; and
• 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 prior to 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 (in the absence of a suppressed viral load) after receiving an HIV diagnosis;
• substance use that may impair judgement;
• mental health conditions, social disadvantage including housing insecurity or domestic and family violence situations which may influence sound judgement or the person’s power to ensure risk minimisation behaviours.

The HPHT/NQHT 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, HHS 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 from within their service 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 living 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.

Appendix 1 provides a summary of the clinician roles for each level of management. Appendix 2 provides a summary diagram of the guideline framework.

5.2 Queensland Police Service liaison

On rare occasions the panel will discuss the case with the CHO who would consider referring a person to the QPS:

• if all efforts to engage the person with case management under the guideline have been unsuccessful, the person appears to be continuing to place others at risk 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 HPHT/NQHT is available to discuss any concerns the clinician feels may warrant referral to the QPS.

The referral to QPS through this guideline process is separate to any referrals clinicians/HHSs may make as part of their mandatory reporting obligations or risk management processes.

5.3 Consent

Where possible and appropriate, the person's consent should be obtained for case discussions between relevant healthcare providers and the panel, and consent obtained for the rare occasion a panel member requires details about the person to assist with their case management to minimise HIV transmission risks. Any confidentiality or privacy concerns should be addressed by the panel. Cases are discussed by the panel using coded names – no identifying details are provided. Where case management at any level of the guideline is recommended, the person should be advised and their cooperation with management sought.

In certain situations, such as the person is uncontactable, cases may be discussed by the panel without consent from the person about whom they are discussing. All cases will be managed in compliance with the privacy and confidentiality provisions of the Public Health Act 2005,   the Hospital and Health Boards Act 2011 (Qld) and the Information Privacy Act 2009 (Qld).

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) and Powers of Attorney Act 1998.

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 HPHT/NQHT;
• accompanying the person to meetings and appointments;
• advocating for the protection of the person’s rights; and
• maintaining confidentiality.

5.5 Human rights

Human rights will be considered in all decisions made.

5.6 Persons in prison

Considerations for people who are in prison whilst under guideline management or following commencement of management under the guideline:

• Any person in prison who is commenced on the guideline will initially be managed on level two, not level one, as the recommended clinician led level one interventions are not usually possible in prison.
• Level two management of a person in prison will be mainly facilitated by the HPHT or NQHT due to the interventions and education required and the ability of the HPHT or NQHT to arrange regular visits, or telehealth appointments etc. The HPHT and NQHT will provide the public health case management aspects as per level one and level two management.
• If a person enters prison already on level one management, they will not be elevated to level two unless there is evidence that justifies escalation of their management, for example, if they did not cooperate with or complete level one management. Their managing clinician will escalate or cease their management based on their review of interventions completed and risk assessment.
• Clinical HIV care will continue to be provided to the person in prison by a HIV clinician.
• Consider ceasing management under the guideline if a person remains in prison and:
  • they have engaged in public health management; and
  • there is no evidence of transmission risks;
• If a person is in prison and under management using the guideline (commenced out of prison or in prison) and they refuse to engage in public health management whilst in prison (usually due to confidentiality issues), the HPHT or NQHT will continue attempts to meet with the person or attempt to organise for public health management from another health provider e.g. prison health staff.
• If a person who is being managed under the guideline (commenced out of prison or in prison) was not engaged in HIV care prior to prison, more education and discussion about community HIV care will occur through the guideline management process. Consider ceasing management if the person:
  • engages in public health management; and
  • there is no evidence of transmission risks
• No person should remain under guideline management in prison for a prolonged period solely to await actions following release, unless there is a justified reason for continued long-term management that will extend post-release.

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

Purpose

Level one case management is initiated by the treating clinician to minimise HIV transmission risk. It is undertaken within the clinician’s service and does not require involvement of the HIV Advisory Panel. However, the panel should be advised of the number of current cases being managed at level one. Any information given to the panel (disclosure) must consider the relevant privacy/confidentiality obligations.

Clinicians may seek assistance from the HPHT or NQHT at any stage.

6.1 Clinician roles and responsibilities

6.1.1 At commencement

• Advise the HPHT or NQHT, that level one case management has been initiated (see letter template in Appendix 3). Any disclosure of identifying information should be done with consideration of the relevant privacy/confidentiality legislated obligations that may apply.
• Document the rationale for case management in clinical notes.
• Inform the person:
  • that placing others at risk of HIV without their consent may be an offence under Queensland law
  • that they are being managed under level one case management; and what this involves (e.g. regular attendance, education, achieving undetectable viral load).
• Encourage HIV treatment as prevention.
• Obtain consent for discussions with relevant healthcare providers.

6.1.2  During management address/complete the following:

6.1.2.1 Promote treatment as prevention

Undertake medical assessment promptly to discuss health benefits of antiretroviral therapy (ART) and its role in preventing HIV transmission.

6.1.2.2 Establish a case management plan

A case management plan may include:

• Scheduled clinical care and monitoring.
• Assistance with contact tracing.
• HIV viral load testing every four months (completed prior to case reviews).
• Peer support and service referrals.
• Monthly reviews for four months.
• Formal review at four months following commencement of guideline management to assess risk and determine continuation (including the option of continuing with one - two monthly reviews), cessation, or escalation of management under the guideline.
• Document ongoing management of the case and the person's attendance and engagement at appointments.

6.1.2.3 Provide education, counselling and referrals

Education and counselling sessions may address:

• Legal responsibility to prevent placing others at risk.
• HIV transmission risks and prevention methods (including ART, PrEP, PEP).
• Skills and supports for safer practices.
• Management of high-risk situations.
• Referrals, for example, engaging government and community organisations where appropriate.

6.1.2.4 Address contact tracing

Support ‘non-statutory’ contact tracing through clinical discussions with the person. This is the process of identifying ‘at risk’ contacts of the person living 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. Importantly, any identifying information may only be disclosed in compliance with relevant privacy and confidentiality laws.

Statutory contact tracing may be undertaken by appointed contact tracing officers under the Public Health Act 2005. Assistance is available from the HPHT/NQHT and local Contact Tracing Support Officers.

6.1.2.5 Review of level one case management

• Conduct monthly reviews of interventions and transmission risk.
• Complete a formal review every four months
• If risk is not being managed, seek guidance from the HPHT/NQHT about referring the case for review by the panel and possible escalation of case management.

6.1.2.6 Transfer of care

If the person transfers their HIV care, in compliance with any relevant privacy and confidentiality laws:

• Advise the new clinician of the person’s case management status so they can continue to provide more intensive education and support as required.
• Advise the HPHT/NQHT of the transfer of care.

6.1.3 Escalation or cessation of level one case management

6.1.3.1 Cessation

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;
• or the person’s behaviour and circumstances are such that escalation to level two (or above) case management is required.

On cessation:

• advise the person that level one management has ceased;
• advise the HPHT or NQHT that level one management has ceased; and
• continue routine monitoring, and ongoing support and care.

6.1.3.2 Escalation

Escalate to level two, or above, management of the person, when:

• Behaviour or circumstances indicate continued risk despite level one management interventions.

On escalation:

• Refer the case to the Chair of the panel (via the HPHT contact details) for review and consideration by the panel with a view to escalating the level of case management. Any disclosure of identifying information should be done with consideration of the relevant privacy/confidentiality legislated obligations that may apply.
• 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 HPHT or NQHT role in level one management

HPHT or NQHT will take the following actions:

• Present the number of cases being managed in Queensland at level one at each panel meeting.
• Provide case management support to the clinician/service as relevant if they have requested the assistance/advice.

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

Purpose

Level two case management is used when a person living with HIV cannot be effectively managed at level one and they continue to pose a risk of HIV transmission. Level two involves the same actions and interventions by the clinician as level one, but with department support, oversight by the panel, and formal case reviews and recommendations.

The purpose of level two management is to engage the person in a more intensive process that promotes behaviour change and minimises HIV transmission risk. People managed at this level should have access to all necessary HIV treatment, counselling, education and support, and be offered the opportunity to nominate a personal advocate.

The HPHT/NQHT can provide guidance throughout. The panel will formally review cases and make recommendations at least every four months.

If a person is unwilling or unable to change their risk behaviours, the clinician should seek assistance from the HPHT/NQHT and/or notify the Chair of the panel. Any disclosure of identifying information should be done with consideration of the relevant privacy/confidentiality legislated obligations that may apply.

The Chair of the panel will write directly to the person, outlining their commencement on level two management and their responsibilities, and the type of cooperation required by them to reduce the risk of HIV transmission. Where the person does not engage in behaviours to reduce the risk of HIV transmission, the Chair of the panel may give the person a ‘warning’ letter, including informing them that escalation to seeking a behavioural order from the court may occur if HIV transmission risks continue.

7.1 Clinician’s role and responsibilities

In addition to providing ongoing clinical care, treatment, counselling, and education, the clinician should:

• refer the case to the Chair of the panel for consideration of level two management.
• document the rationale in clinic notes for escalation, including documentation of why level one management was not effective;
• maintain interventions to reduce risk of HIV transmission;
• implement recommendations from the panel and facilitate any referrals;
• inform the person they may seek support from an advocate;
• obtain the person's consent for case discussions between relevant healthcare providers;
• provide a report to the panel as requested;
• if requested, participate in meetings held by the panel, to provide advice and information to the panel.
• ensure any disclosure of identifying information should be done with consideration of the relevant privacy/confidentiality legislated obligations that may apply.

7.1.1 Case referral

When referring a person to the Chair of the panel, the clinician should, at a minimum, provide the following information:

• specific concerns and details of HIV transmission risk and interventions attempted under level one and why they were not effective;
• current assessment of the person’s clinical management and HIV transmission risk; and
• any other relevant supporting documentation.

Referrals may be submitted via the HPHT or NQHT referral forms or by writing to the Chair of the HIV Advisory Panel via HIV_PH_Team@health.qld.gov.au.

7.1.2 Case management plan and case manager

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

• Be based on a comprehensive medical and public health assessment.
• Outline agreed actions, timeframes, and scheduled consultations.
• Schedule at least monthly contact with the person for the first four months, then:
  • two-monthly contact with the person if the risk of HIV transmission is reduced
  • leave at, or revert to, monthly contact with the person if the HIV transmission remains unmanaged
• Schedule HIV viral load tests of the person every four months.
• Assign a case manager, as determined by usual processes in place in services, this may be a nurse who specialises in case management, to coordinate care and monitor progress of the person.

7.1.3 Review case management

Monthly reviews should assess:

• the effectiveness of any interventions; and
• the ongoing risk of HIV transmission by the person.

7.1.4 Clinician report for the HIV Advisory Panel

For persons being managed under the guideline, their clinicians may be requested to provide the following information to the panel:

• date of last review and next appointment;
• assessment of engagement in HIV treatment and care;
• results from recent HIV and STI tests;
• summary of assessments and interventions;
• an assessment of the person’s willingness and ability to prevent placing others at risk of HIV;
• assessment of the person’s HIV transmission risk;
• other information or concerns to be brought to the attention of the panel; and
• recommendations for management, including an opinion on whether the person should remain on their current level of case management under the guideline, be escalated or deescalated, or cease case management under the guideline.

If risk behaviours persist or engagement is limited, the clinician should notify the HPHT/NQHT and/or advise the Chair of the panel.

7.2 HPHT/NQHT role in level two management

The HPHT or NQHT for cases in their relevant region, will:

• ensure the initiation of formal commencement of level two case management, which includes attempting to obtain the person’s agreement to cooperate in reducing HIV transmission;
• liaise with clinicians on assessments, risk management, case planning, referrals, and contact tracing;
• ensure level two case management is being attempted to be implemented;
• present case reports to the panel;
• obtain the person’s consent for case discussions at the panel; and
• provide feedback to the clinician from the panel in compliance with confidentiality and privacy laws.

7.3 Maintenance, escalation, de-escalation or cessation

At each review, the panel, including the Chair, will discuss and reach a consensus opinion on whether to:

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

The panel will consider

• opinions and feedback from the managing clinician/service;
• implementation of previous recommendations;
• effectiveness of the interventions in reducing risk of HIV transmission;
• person’s understanding of HIV transmission risks and how to prevent transmission;
• duration of time the person has been managed under the guideline;
• length of time since last transmission risk. Eight months or more of the person engaging/cooperating with case management under the guideline may be effective for the behaviour change to prevent placing others at risk of HIV;
• evidence of current/recent (past 4-8 months) of placing others at risk of HIV;
• reasons to justify maintaining the person on guideline management

When level two case management ends, the panel will formally notify both the clinician and the person of this.

7.4 Consent/cooperation withdrawal

If a person managed on level two of the guideline withdraws their consent to cooperate with case management under the guideline, their case may be considered to be closed and management under the guideline ceased, if all the following apply:

• The person has been educated and counselled about minimising behaviours that place others at risk of HIV.
• The person understands their responsibilities not to place others at risk of HIV.
• The person understands strategies to prevent placing others at risk of HIV.
• There is no evidence that the person is currently placing others at risk of HIV or poses a HIV transmission risk.
• The person is aware of services or persons to contact if they chose to engage in further public health management or HIV treatment and care (if currently choosing not to engage in HIV treatment and/or care).
• The person has provided a written, ideally signed, statement acknowledging they no longer consent to cooperate with case management under the guideline, and they will not place others at risk of HIV.

7.5 Refusal to consent to commence guideline management

If a person refuses to consent to commence with case management under the guideline, then the HPHT or NQHT will continue attempts to contact and obtain the person’s consent, using methods and frequency as instructed by the panel.

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

Purpose

Level three case management is used when a person living with HIV cannot be effectively managed at level one and level two and they continue to pose a risk of HIV transmission.

Level three case management involves managing a person under a court ordered ‘behavioural order’ [controlled notifiable conditions order] made under Chapter 3, Part 5, Division 3 of the Public Health Act 2005.

Level three case management is undertaken by the clinician, with department support, case reviews and recommendations.

The panel may recommend level three case management when a person on level two case management is:

• unwilling or unable to modify their behaviour, which may be placing others at risk of HIV; or
• able but unwilling to change behaviour which may be placing others at risk of HIV and refuses to engage in level one or level two interventions; and
• there is evidence of HIV transmission risks.

The HPHT/NQHT can provide support and assistance. HHS clinicians should liaise with their HHS legal unit, and private providers should liaise with their legal representatives, 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.

Criteria for a behavioural order

A behavioural order may only be sought if the following conditions are met (section 125 of the Public Health Act 2005):

• the person has a controlled notifiable condition;
• their condition and/or likely behaviour constitute an immediate risk to public health;
• restrictions are necessary to prevent risk to public health; and
• the person has been counselled, or reasonable attempts have been made to counsel the person, about the condition and its possible effect on the person’s health and on public health.

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 existing behavioural order to be extended, varied or revoked by a magistrate under the Public Health Act 2005.

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 Public Health Act 2005 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 Public Health Act 2005).

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

• attend and engage in appointments for HIV care;
• attend and engage in other relevant appointments;
• undergo clinical assessment including laboratory testing as required;
• 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. Any disclosure of identifying information should be done with consideration of the relevant privacy/confidentiality legislated obligations that may apply.

Correspondence between the Chair of the panel and with the relevant legal team, will commence as soon as the panel recommends the person is being considered to be elevated to level three or level four management under the guideline. Although the panel will progress the application for a behavioural order under the Public Health Act 2005, the relevant legal team will review/assist with the documents required and will file the order in the court.

Process for obtaining a behavioural order

Phase 1: Gain approval

• The panel will seek approval from the chief executive (or delegate) to apply for an order – this approval request needs to include:
  • the application for a behavioural order;
  • an affidavit from the clinician detailing the medical grounds, risk to public health, and supporting evidence for the court order;
  • any other relevant legal forms; and
  • a draft behavioural order for the magistrate, detailing any conditions for the person to comply with (see section 126 of the Public Health Act 2005).

Phase 2: Application to the magistrate

• The chief executive (or delegate) can apply for a behavioural order under the Public Health Act 2005 to the magistrate.
• Legal advice and assistance should be sought by both the clinician and the Chair of the panel.
• The application, with any supporting documents, is filed in the magistrate’s court. For HHS cases, this is usually done via the local HHS legal unit.
• The person should be notified of the hearing; however, if the person does not attend the hearing of the matter before the court, this does not prevent the court from making an order (under section 117 of the Public Health Act 2005).
• The magistrate may want to hear in-person from clinicians or other departmental/HHS employees involved in the application.
• Evidence of appropriate delegations and a draft behavioural order should be taken to the court.

The magistrate may:

• make the order sought;
• vary the order; or
• refuse to make the order.

Phase 3: Serving the order

Some department/HHS officers have been appointed as authorised persons under the Public Health Act 2005 and may serve behavioural orders. As soon as practicable after the order is made, an authorised person must serve the order on the person (if the person is able to be located).

If the person is not able to be located, the court order should remain on the file held by the relevant entity who sought the order and be served if the person is subsequently located.

Phase 4: Record keeping

The authorised person who serves the order must document the details of their activities associated with serving the order and give the information to the person as detailed in section 127 of the Public Health Act 2005, including that it is an offence to not comply with the order.

Phase 5: Extension, variation, or revocation

• Orders may be extended, varied or revoked by a magistrate on application from the chief executive (or delegate).
• The panel will review cases every two months and advise on continuation, escalation, variation, extension or revocation.

8.1 Clinician’s role

The clinician should continue to provide routine HIV care (treatment, counselling, education and support) and other relevant level one and level two case management interventions, and will:

• seek legal advice and assistance as needed;
• advise the person to consider seeking legal advice and support from an advocate;
• assist in preparing affidavits and draft orders;
• assist in the preparation of a behavioural order application for the chief executive (or delegate) approval;
• assist in development of a draft behavioural order and assist with the process of obtaining the order;
• initiate a comprehensive medical assessment;
• adapt the case management plan to reflect any requirement made under the behavioural order (if made);
• ensure all relevant activities associated with the behavioural order are comprehensively documented;
• monitor the person’s cooperation with the behavioural order and case management plan; and
• If the clinician considers that an existing behavioural order should be extended, varied or revoked, liaise with the HPHT/NQHT and/or the Chair of the panel and provide relevant details for the chief executive (or delegate) who will determine whether to make this application to the court.

8.2 HPHT/NQHT role in level three management

The HPHT/NQHT will:

• Provide assistance in all stages of the application process and drafting relevant documents.
• Provide advice or support to the clinician to implement conditions stated in the order e.g. assessments, education, engagement in HIV care etc.
• Ensure attempts are made for the person to be advised of peer support, advocacy, and seeking legal advice.
• Provide case updates to the panel as relevant and communicate recommendations from the panel to the relevant clinicians.

8.3 Maintenance, escalation or de-escalation

In consultation with the clinician, the panel will regularly review cases and may:

• continue level three case management of the person;
• escalate or de-escalate the level of case management of the person; or
• cease case management of the person 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 there is evidence of ongoing HIV transmission risks and 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 of the person 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.

Purpose

Level four case management is used when a person cannot be effectively managed at level one, level two or level three and they continue to pose a risk of HIV transmission. Level four case management involves obtaining a detention order (controlled notifiable conditions order) made by a magistrate under Chapter 3, Part 5, Division 4 of the Public Health Act 2005. 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 Public Health Act 2005, legal advice should be sought by both the clinician and the department.

A person cannot be detained under a detention order unless the magistrate, is satisfied:

• the person has a controlled notifiable condition;
• the person’s condition, or their condition and likely behaviour may pose an immediate risk to public health;
• detention at a stated place for a stated period is necessary to avoid the person’s condition, or their condition and likely behaviour, constituting a risk to public health; and
• the person has been counselled, or reasonable attempts to counsel them have been made, about their condition and its possible effects on their own health and public health.

Applications should request closed court hearings and non-publication orders to protect the identity of the person living with HIV.

Detention may occur at a person’s residence (although this may be difficult to monitor) or within a supervised environment, such as at a health facility. Sections 130(1) and (3) of the Public Health Act 2005 specify actions covered by a detention order, and conditions a magistrate may impose.

Following completion of the period of detention, the person will likely be managed at level three or level 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 Public Health Act 2005.

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.

Correspondence between the Chair of the panel and with the relevant legal team will commence as soon as the panel recommends the person is being considered to be elevated to level three or level four management under the guideline. Although the panel can progress the application for a behavioural order under the Public Health Act 2005, for HHS clinicians, the HHS legal team will review/assist with the documents required and file the application for an order with the court.

Process for obtaining a detention order

Phase 1: Gain approval

• Panel seeks approval from the chief executive (or delegate) to apply for an order – this approval request needs to include:
  • the application for a detention order;
  • an affidavit from the clinician detailing the medical grounds, risk to public health, and supporting evidence for the court order;
  • any other relevant legal forms; and
  • a draft detention order for the magistrate, detailing any conditions for the person to comply with (see section 130 of the Public Health Act 2005).

Phase 2: Application to the magistrate

• The chief executive (or delegate) can apply for a detention order under the Public Health Act 2005 to the magistrate.
• Legal advice and assistance should be sought by both the clinician, for example, a HHS clinician should seek assistance from their HHS, and the Chair of the panel from the department legal unit.
• The application, with any supporting documents, is filed in the magistrate’s court. This is usually done via the local HHS legal unit.
• The person should be notified of the hearing; however, if the person does not attend the hearing of the matter before the court, this does not prevent the court from making an order (under section 117 of the Public Health Act 2005).
• The magistrate may want to hear in-person from clinicians or other departmental/HHS employees involved in the application.
• Evidence of appropriate delegations and a draft detention order should be taken to the court.

The magistrate’s court is contacted, usually by the relevant HHS legal unit, to arrange for the matter to be listed and heard before a magistrate.

The magistrate may:

• make the order sought;
• vary the order; or
• refuse to make the order.

Phase 3: Serving the order

Some department/HHS officers have been appointed as authorised persons under the Public Health Act 2005 and may serve detention orders. As soon as practicable after the order is made an authorised person must serve the order on the person (if the person is able to be located).

If the person is not able to be located, the court order should remain on the file held by the relevant entity who sought the order and be served if the person is subsequently located.

Phase 4: Record keeping

The authorised person who serves the order must document the details of their activities associated with serving the order and give the information to the person as detailed in section 131 of the Public Health Act 2005, including that it is an offence to not comply with the order.

Phase 5: Clinical examination and assessments

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

• explain the purpose of examinations, assessments, or treatment in understandable terms; and
• allow the person an opportunity to voluntarily submit to the examination, assessment or treatment.

Phase 6: Place of detention

Detention must occur at the location stated in the order (e.g., residence, public health facility).

Phase 7: Warrant for apprehension

If a person absconds from a place they are required to be detained at under the detention order, an authorised person may apply to a magistrate for a warrant of apprehension for that person. Legal advice should be sought in these circumstances.

Phase 8: Extension, variation or revocation

A detention order may be extended only once for not more than 28 days or may be varied or revoked under the Public Health Act 2005. The panel will review the case and make recommendations accordingly.

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

The relevant magistrate’s court registrar must be contacted to arrange for the matter to be listed and heard before a magistrate. The chief executive (or delegate) can apply for a detention order to be extended, varied or revoked by a magistrate under the Public Health Act 2005.

9.1 Clinician’s role

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

• seek legal advice and assistance as needed;
• advise the person to consider seeking legal advice and support from an advocate;
• identify suitable options for the place of detention;
• assist to prepare documentation for chief executive (or delegate) approval;
• provide affidavit(s) 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;
• assist with the process of obtaining the order;
• ensure all relevant activities associated with the detention order are comprehensively documented;
• provide encouragement and intensive support to the person throughout the period of detention;
• undertake or organise the required examinations and/or assessments; and
• continue case management of the person after the expiry of the detention order, taking into consideration any recommendations made by the panel.

9.2 HPHT/NQHT role in level four management

The HPHT/NQHT will:

• Provide assistance at all stages of the application process and with drafting relevant documents.
• Provide advice or support to the clinician to implement conditions stated in the order e.g. assessments, education, engagement in HIV care etc.
• Ensure attempts are made for the person to be advised of peer support, advocacy, and seeking legal advice.
• Provide case updates to the panel as relevant and communicate recommendations from the panel to relevant clinicians.

9.3 Maintenance, escalation or de-escalation

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

• at level three or level two of the guideline’s case management framework; or
• 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 Public Health Act 2005.

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

10. Clinician role in case management for transient/unlocatable persons

A person who is placing others at risk of HIV, or has placed others at risk of HIV, and is highly mobile or transient in Queensland or not able to be located may be difficult to link to a Queensland Health sexual health service.

The referring clinician/service and/or last managing clinician/service should continue attempts to contact the person every three months.

HPHT/NQHT will attempt to locate and contact the person at a frequency as recommended by the panel.

A person should be linked into HIV care with the Queensland Health sexual health service in the HHS where the person resides, or S100 practitioner/private provider, as soon as they are located.

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. 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. (2025). 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.

The HPHT/NQHT can provide advice about any aspects of levels 1-4 management.

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 CHO liaison with the Queensland Police Service.

Appendix 3: Letter template for advising the HPHT, NQHT or Chair of the HIV Advisory Panel of commencement of level one management

Download the letter template

Appendix 4: Report template for providing the Chair of the HIV Advisory Panel with a management update

Download the letter template (DOC 33 kB).

Review

This Guideline is due for review on: 13 March 2029

Date of Last Review: 27 March 2026

Supersedes: Version 2.0

Business Area Contact

Communicable Diseases Branch

Approval and Implementation

Guideline Custodian

Executive Director, Communicable Diseases Branch

Endorsed by:  Queensland HIV Advisory Panel

Endorsement date: 27 March 2026

Approving Officer

Chief Health Officer and Deputy Director-General, Population Health Division

Approval date: 13 March 2026

Effective from: 27 March 2026

Version Control

Change Table