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Formulating public health policy: managing difficult HIV cases.
Thompson D; Addrien A; Jurgens R; Lambert G; Canadian HIV-AIDS Legal
January 30, 1997
Int Conf AIDS. 1996 Jul 7-12;11(2):408 (abstract no. Th.D.5013). Unique

Objectives: To develop a comprehensive public health policy to deal with HIV-positive persons who are unwilling or unable to maintain safe behaviours. This policy is directed towards the prevention of HIV transmission and the protection of infected individuals. Methods: 1) Literature review of approaches adopted in Canada and elsewhere; 2) Documentation of a broad variety of scenarios through in-depth interviews with representatives of key individuals from affected communities, clinicians, social workers, a psychiatrist, a bio-ethicist, lawyers, and public health professionals; problems and solutions raised by these cases were also discussed; 3) Review of applicable provincial and federal legislation; 4) Drafting of a discussion paper; 5) A participatory approach with inclusion of all stakeholders including extensive consultation and case presentations. Results: The review of the legislation showed that, in contrast to the United States, there is currently no HIV- or STD-specific criminal legislation in Canada applicable to those who knowingly transmit HIV; its validity in its application to HIV has yet to be determined. Most court cases of unwilling or unable persons have involved heterosexual activity, although gay men are the population most affected by the epidemic. The process resulted in the different stakeholders involved taking ownership of the issue. There was consensus that a preventive and enabling approach rather than a coercive one would be more successful in protecting public health: improved pre- and post-test counselling; education campaigns towards HIV-positive persons, physicians and counsellors; better access to condoms, lubricants and clean needles. Indicators of likeliness to transmit HIV and a sliding scale of personal control measures were developed beginning with the least intrusive and restrictive measures and intruding progressively on personal freedom upon each irrefutable proof of noncompliance. A case management model remains to be finalized and implemented. It will integrate representation from public health, the affected communities and clinicians. Conclusions: To develop a successful policy to deal with this issue, Public Health needs to involve affected communities as well as people who have better access to these communities. This approach raised some important challenges: accountability of Pubic Health and community representatives; cultural differences between heterosexual and gay populations in analyzing and assessing risk-taking behaviour; difficulty in including hard-to-reach communities such as IDU.

*HIV Infections/PREVENTION & CONTROL *HIV Infections/TRANSMISSION *HIV Seropositivity/TRANSMISSION *Public Health *Public Policy