Carol L. Galletly

Conflicting Messages: How Criminal HIV Disclosure Laws Undermine Public Health Efforts to Control the Spread of HIV

Twenty-three U.S. states currently have laws that make it a crime for persons who have HIV to engage in various sexual behaviors without, in most cases, disclosing their HIV-positive status to prospective sex partners. As structural interventions aimed at reducing new HIV infections, the laws ideally should complement the HIV prevention efforts of public health professionals. Unfortunately, they do not. This article demonstrates how HIV disclosure laws disregard or discount the effectiveness of universal precautions and safer sex, criminalize activities that are central to harm reduction efforts, and offer, as an implicit alternative to risk reduction and safer sex, a disclosure-based HIV transmission prevention strategy that undermines public health efforts. The article also describes how criminal HIV disclosure laws may work against the efforts of public health leaders to reduce stigmatizing attitudes toward persons living with HIV.

A dynamic social systems model for considering structural factors in HIV prevention and detection

We present a model for HIV-related behaviors that emphasizes the dynamic and social nature of the structural factors that influence HIV prevention and detection. Key structural dimensions of the model include resources, science and technology, formal social control, informal social influences and control, social interconnectedness, and settings. These six dimensions can be conceptualized on macro, meso, and micro levels. Given the inherent complexity of structural factors and their interrelatedness, HIV prevention interventions may focus on different levels and dimensions. We employ a systems perspective to describe the interconnected and dynamic processes of change among social systems and their components. The topics of HIV testing and safer injection facilities (SIFs) are analyzed using this structural framework. Finally, we discuss methodological issues in the development and evaluation of structural interventions for HIV prevention and detection.

Reducing HIV Transmission Risk by Increasing Serostatus Disclosure: A Mathematical Modeling Analysis

Persons living with HIV infection are encouraged to disclose their HIV-positive serostatus to prospective sex partners to decrease the likelihood of unsafe sex and HIV transmission. However, the effectiveness of serostatus disclosure as a preventive measure is not known. We developed a mathematical framework for assessing the HIV transmission risk reduction effectiveness of serostatus disclosure, examined how increasing the disclosure rate affects the transmission risk reduction effectiveness of disclosure, and explored the interaction between condom use and disclosure effectiveness. Under base-case assumptions, serostatus disclosure reduced the risk of HIV transmission by between 17.9% and 40.6% relative to no disclosure. Increasing the disclosure rate from the base-case value of 51.9–75.7% produced a 26.2–59.2% reduction in risk. The findings of this modeling study strongly support intervention efforts to increase both serostatus disclosure and condom use by persons living with HIV.

Infections Prevented by Increasing HIV Serostatus Awareness in the United States, 2001 to 2004

Background:Persons living with HIV (PLWH) who are aware of their HIV status are more likely than serostatus-unaware PLWH to take precautions to prevent HIV transmission to their partners. The estimates of the Centers for Disease Control and Prevention (CDC) indicate that the proportion of PLWH who were aware of their serostatus increased between 2001 and 2004. The epidemiologic consequences of this increase in serostatus awareness are unknown. Methods:We developed a basic model of the US HIV epidemic from 2001 to 2004. Using this model, we calculated the number of incident infections that would have occurred in 2002 to 2004 had the proportion of PLWH who were aware of their serostatus remained at its 2001 level rather than increasing between 2001 and 2004. We then compared this incidence estimate with the CDCs estimated total of 120,000 incident infections in 2002 to 2004 to determine the number of infections prevented by the increase in serostatus awareness. Results:The increase from 2001 to 2004 in the proportion of PLWH who were aware of their serostatus can be credited with preventing nearly 6000 incident HIV infections in the 3-year period from 2002 to 2004. Sensitivity analyses indicated a plausible range of 4000 to 8700 prevented infections. Conclusion:This analysis demonstrates the important epidemiologic benefits of increasing the proportion of PLWH who are aware of their HIV status.

HIV seropositive status disclosure to prospective sex partners and criminal laws that require it: perspectives of persons living with HIV.

Thirty-one HIV-positive persons living in Michigan took part in focus group discussions about Michigans HIV disclosure law. Discussion themes included perceived responsibility to prevent infection, concern about unwanted secondary disclosure of HIV-positive status, fear of being falsely accused of violating Michigans HIV disclosure law and perceived vulnerability of HIV-positive persons within the US legal system. Although participants strongly agreed with the ostensible purpose of Michigans criminal HIV disclosure law, there was considerable concern about the negative impact of the law on persons living with HIV.

Sexual health curricula in U.S. medical schools: current educational objectives.

ObjectiveThe authors identify the explicit and implicit objectives that shape decisions about what medical schools teach regarding human sexuality.MethodsThe authors reviewed relevant articles in journals, physician licensing examinations, and publications by professional organizations to identify learning objectives for human sexuality in undergraduate medical curricula.ResultsThere is consensus about many of the attitudinal objectives and some of the skills medical students should acquire in sexual health. There is less consensus on the sexuality-related information student physicians need to master. The few common informational objectives focus narrowly on diagnosing sexual dysfunction and disease.ConclusionThe model sexual health curricula, licensing exams, and guidelines from professional organizations mainly focus on the pathological aspects of sexuality. Student physicians should master fundamental information on healthy sexual function and become familiar with the roles of practitioners in various therapeutic disciplines in addressing sexual concerns and enhancing patients’ sexual functioning and well-being. Instruction should also address ways to incorporate this important topic in time-limited interactions with patients.

Model-Based Estimates of HIV Acquisition Due to Prison Rape

Nearly 1.4 million men are incarcerated in federal and state prisons in the United States. These men are disproportionately affected by HIV in comparison with the at-large male population. The elevated prevalence of HIV infection in U.S. prisons has raised concerns over the potential for intraprison HIV transmission due to rape and other forms of sexual victimization. However, the number of men who acquire HIV after being raped in U.S. prisons is not known. We developed a mathematical model of HIV transmission to estimate the likelihood that an incarcerated man would become infected as a result of prison rape and to provide preliminary estimates of the number of prison rape victims who acquire HIV. Our results suggest that between 43 and 93 currently incarcerated men already have or will acquire HIV as a result of being raped in prison.

HIV-Positive Persons’ Awareness and Understanding of Their State’s Criminal HIV Disclosure Law

Commentary on the potential impact of HIV-specific disclosure laws on persons living with HIV has been critical, plentiful, and enduring. Yet empirical information with which to answer even the most basic questions about these laws, such as whether HIV-positive persons living in a state with a disclosure law are aware of the law, is absent. This study reports on data gathered from a statewide sample of 384 HIV-positive persons living in a state with an HIV disclosure law. Participant awareness and understanding of the law were assessed. Data on the sources from which participants received information on the law and the perceived helpfulness of these sources were also collected. Analyses were conducted to identify associations between participant awareness or understanding of the law and demographic characteristics of participants or information sources encountered. The majority of participants were aware that their state had enacted an HIV-specific disclosure law. Understanding of the law was good, although there was substantial confusion over several provisions. The most prevalent and most helpful sources of information on the law were AIDS-related resources as opposed to mass media. Forty-two percent of the participants learned about the law when first diagnosed with HIV. Sixty-two percent of the participants reported that their case manager had told them about the law.

Toward rational criminal HIV exposure laws.

This article examines criminal HIV exposure statues that address undisclosed exposure through consensual sexual activity. Twenty-seven U.S. states have adopted some form of HIV exposure statute. Thirteen of these statutes specifically address exposure through sexual activity, while another eleven statutes could be applied to exposure through sexual activity, while another eleven statutes could be applied to exposure through consensual sexual interactions. Although the penalties for breach of these laws are often severe, the risk of actual harm posed by the many of the behaviors prescribed is minimal and in some cases virtually nonexistent. After an overview of the various types of U.S. criminal HIV exposure statutes and discussion of the risk of HIV transmission through the various sexual activities addressed in the laws, the authors highlight the tenuous relationship between proscribed activities and actual risk of virus transmission. The authors address this limitation in the law by offering a framework for the evaluation and construction of HIV exposure statutes that considers not only the intent of the HIV-positive actor but also the risk that his or her conduct poses to others.

Lesbian, Gay, Bisexual, and Transgender Communities’ Readiness for Intimate Partner Violence Prevention

Efforts to address intimate partner violence (IPV) in lesbian, gay, bisexual, and transgender (LGBT) communities often rely on identifying what service providers can do to better reach and serve these populations. However, assessing a communitys readiness in response to the issue of IPV in LGBT communities locates the issue where outcry is most likely to occur. Utilizing the Community Readiness Model in lesbian, gay, bisexual, and transgender communities in two rural and two urban communities, this study revealed a low level of community readiness to address IPV. Only vague awareness of IPV exists in these sexual orientation, gender identity, and geographic communities. The study suggests specific next steps tailored to raise LGBT communities’ readiness to address IPV from within their own communities, starting at the current low level.