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Saturday, September 03, 2011

LEGISLATIVE VICTORY IN CALIFORNIA: HELP WITH HIV PARTNER NOTIFICATION

A bill to help physicians obtain public health assistance with HIV contact tracing and partner notification has passed the California legislature. Governor Brown signed  Senate Bill 422 into law on August 1, 2011. The bill was sponsored by Beyond AIDS, and introduced by Senator Roderick Wright.  It will take effect in January 2012.
Roderick Wright (center), holding Beyond AIDS award for previous HIV legislation, with Presdient Ron Hattis (left) and Past-President Cary Savitch (right)

The new law will allow a physician, with the patient's consent, to inform local public health staff that the patient may have exposed other persons to HIV. The public health staff can then interview the patient, elicit information on partners and details on how they can be reached, and can help assure that these exposed persons are notified, counseled, and referred for testing and follow-up. The local public health agency will be able to retain information about the partners until those services are complete. Both the physician and the local public health staff will be protected from liability.

Up to now, it has been illegal for a California physician to identify a patient, who may have exposed others to HIV, to local public health agency staff. As a result, physicians have not been able to request that the patient be interviewed to identify possible exposed partners by trained public health staff. A physician who has wished partners to be notified of their exposure has had to perform the interview him or herself. The physician could name the identified partners to the local health officer (it was unclear whether other public health staff were covered under that term), but could not pass on information about who the infected patient was and how that person could be reached.

Partner services include coaxing infected patients to reveal their sexual and needle-sharing partners, eliciting information on how to reach those persons, and performing the actual notification, counseling, and referrals. Most physicians do not have the time or the special training and experience to perform partner services, and any such services are not compensated by insurance or any other funding source. As a result, partner services, including the actual notification and referral of the exposed partners, are greatly under-utilized as a prevention tool.  Local public health agencies do have trained staff assigned to this function, but due to the limitations of the law, in many counties few partners are notified. Most of the patients whose partners have been notified by public health staff have been those who are being treated in clinics operated of the local public health agency itself.

When public health staff notify a partner, the name of the infected source is not revealed. Because of this,  patients may often be willing to reveal to public health staff the identity of partners and how to reach them, even though they would be unwilling to tell the partners themselves. Some patients also would be embarrassed to reveal all their partners to their physicians, but would do so to neutral public health workers pledged to confidentiality.

While some patients notify their own partners and refer them for testing, studies have shown that this does not happen most of the time. There may be well-founded fears of rejection by the partner, or even fears of physical abuse. Frequently, partners have been anonymous or have moved on and been lost to follow-up, so that a patient cannot reach them even if he or she wants to; but with enough information on where the partners "hang out" and their descriptions, public health staff may be able to locate and notify them.

If performed effectively, partner services can help stop HIV transmission. If an exposed partner tests negative for HIV and is lucky enough not to have already been infected, precautions can be taken to avoid infection. If the partner tests positive, he or she can be promptly directed to medical care and follow-up, and assisted in not infecting anyone further. Thus, the chain of infections can be interrupted.

SB 422 is expected to be a step toward better communication between physicians and local public health staff about HIV exposures, and an advance in efforts to stop HIV transmission. This is part of the mission of Beyond AIDS.

The bill as passed was somewhat of a compromise. Several additional provisions proposed by Beyond AIDS were opposed by the American Civil Liberties Union and could have resulted in the bill's defeat, so they were not included. Among these were expanding the bill to include nurse practitioners and physician assistants as well as physicians, and to permit the bill to also deal with exposures to blood or other infectious substances of infected persons other than needle sharing, as in trauma situations or surgical accidents. Beyond AIDS also wished to eliminate the need for written consent by the patient for referrals to public health, since all cases should have already been reported to public health and thus should not be new disclosures of the patient's infected status. Beyond AIDS will evaluate whether there is sufficient political support for an expanded bill in 2012.

Beyond AIDS President Ron Hattis has expressed the organization's appreciation and recognition to Stan DiOrio, Senator Wright's tireless Legislative Director, without whom the new law could never have become a reality. This is the fourth bill related to HIV prevention that Roderick Wright has introduced for Beyond AIDS (earlier as an Assembly Member, and now as a Senator), and the second one signed into law. The California Academy of Preventive Medicine, Infectious Disease Association of California, AIDS Healthcare Foundation, and California Medical Association provided supporting letters and testimony.

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