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

Life and love under criminalization: The experiences of people living with HIV in Canada

Based upon qualitative interviews with 54 women and men living with HIV across Ontario, Canada, this paper examines the impact of HIV criminalization on the sexual and romantic relationships of people living with HIV. This research highlights the navigation strategies people living with HIV create and employ to both navigate and protect themselves from the law. Through a thematic and intersectional analysis, this study shows how adoption of these strategies is unequal, with access to navigation strategies varying along lines of gender, race, and sexual orientation. As a result, women and racialized people living with HIV face more difficulties navigating the impact of the law. HIV criminalization in Canada fuels and validates HIV stigma and produces vulnerability both within and outside of the relationships of people living with HIV. This paper seeks to understand HIV criminalization from the perspective of those governed by the law, in hopes of producing knowledge which will contribute to legal reform, inform policy, and support the development of efficacious secondary prevention initiatives.

Substance Use, HIV Serostatus Disclosure, and Sexual Risk Behavior in People Living with HIV: An Event-Level Analysis

People living with HIV (PLWH) face difficult decisions about disclosing their HIV status to new sexual partners. Alcohol and other drug use could impact these decision-making processes and subsequent sexual risk behavior. We sought to examine the event-level relationships between substance use, HIV disclosure, and condom use in PLWH and their first-time HIV-negative or unknown status sexual partners. Adult PLWH were recruited from care settings in a southeastern U.S. city. Participants reported their sexual behavior for 28 consecutive days via text message prompts. We employed multilevel covariation in a causal system to examine the event-level relations between substance use and condom use. We proposed that this relationship would be mediated by HIV disclosure and moderated by viral suppression status. A total of 243 participants (83% male, 93% Black) reported 509 sexual events with first-time HIV-negative/unknown status sexual partners. Substance use at the time of sex was negatively associated with disclosure in PLWH with suppressed viral load (OR 0.29, β = - 1.22, 95% CI [- 2.42, - 0.03], p = .045), but differentially associated with condom use in PLWH with detectable versus undetectable viral load. In PLWH with viral suppression, participants who always disclosed versus who never disclosed their HIV status were more likely to use condoms (β = 1.84, 95% CI [0.35, 3.53], p = .017), but inconsistent disclosers were less likely to use a condom after disclosing (OR 0.22, 95% CI [0.07, 0.68], p = .008). Event-level analysis offers a more nuanced understanding of the proximal (substance use, HIV disclosure) and person-level (substance use, viral load) determinants of HIV transmission risk behavior in PLWH.

Sexual (Dis)satisfaction and Its Contributors Among People Living with HIV Infection in Sweden

Earlier research reports lower sexual satisfaction among people living with HIV (PLHIV) compared to HIV-negative persons. A number of psychosocial factors directly associated with sexual dissatisfaction have been identified. Little is known about sexual satisfaction and their contributors among PLHIV in Sweden. The aim of this study was to examine direct and indirect effects of variables within sociodemographic, clinical HIV-related, psychological, and sexual domains on sexual (dis)satisfaction among PLHIV in Sweden. Data for this study were derived from a nationally representative, anonymous survey among PLHIV conducted in 2014 (n = 1096). Statistical analysis included four steps: descriptive analyses, identification of variables associated with sexual (dis)satisfaction, identification of variables associated with those contributors of sexual (dis)satisfaction, and a path model integrating all these analyses. A total of 49% of participants reported being sexually dissatisfied, and no significant differences were observed when non-heterosexual men, heterosexual men, and women were compared. Among women, a negative change in sex life after HIV diagnosis and distress with orgasmic difficulties was directly associated with sexual dissatisfaction. For men, hopelessness, high HIV stigma, sexual inactivity in the last 6 months, and a negative change in sex life after HIV diagnosis were directly associated with sexual dissatisfaction. Path analyses showed in both men and women significant indirect associations between not being involved in an intimate relationship, lower self-reported CD4 cell counts, and perceiving obligation to disclose HIV status to sexual partners as a barrier to look for a long-term partner and sexual dissatisfaction. Our results show that despite good treatment outcomes, the HIV diagnosis has a negative bearing on sexual satisfaction. The need for gender-tailored interventions and clinical implications of these findings are discussed.

Positive sexuality: HIV disclosure, gender, violence and the law-A qualitative study

While a growing body of research points to the shortcomings of the criminal law in governing HIV transmission, there is limited understanding of how cis and trans women living with HIV (WLWH) negotiate their sexuality and HIV disclosure in a criminalized environment. Given the ongoing criminalization of HIV non-disclosure and prevalence of gender-based violence, there is a critical need to better understand the dynamics of negotiating sexual relationships and HIV disclosure among WLWH. We conducted 64 qualitative interviews with cis and trans WLWH in Vancouver, Canada between 2015 and 2017. The interviews were conducted by three experienced researchers, including a cis and a trans WLWH using a semi-structured interview guide. Drawing on a feminist analytical framework and concepts of structural violence, the analysis sought to characterize the negotiation of sexual relationships and HIV disclosure among WLWH in a criminalized setting. For many participants their HIV diagnosis initially symbolized the end of their sexuality due to fear of rejection and potential legal consequences. WLWH recounted that disclosing their HIV status shifted the power dynamics in sexual relationships and many feared rejection, violence, and being outed as living with HIV. Participants' narratives also highlighted that male condom refusal was common and WLWH were not only subjected to the gendered interpersonal violence of male condom refusal but also to the structural violence of legislation that requires condom use but fails to account for the gendered power imbalance that shapes condom negotiation. Despite frequently being represented as a law that 'protects' women, our findings indicate that the criminalization of HIV non-disclosure constitutes a form of gendered structural violence that exacerbates risk for interpersonal violence among WLWH. In line with recommendations by, the WHO and UNAIDS these findings demonstrate the negative impacts of regulating HIV prevention through the use of criminal law for WLWH.

"You just can't trust everybody": the impact of sexual risk, partner type and perceived partner trustworthiness on HIV-status disclosure decisions among HIV-positive black gay and bisexual men

HIV remains an intractable public health concern in the USA, with infection rates notably concentrated among Black gay and bisexual men. Status disclosure by HIV-positive individuals can be an important aspect of risk reduction but doing so poses dilemmas concerning privacy, stigma and self-protection, especially among populations subjected to multiple types of stigmatisation. Understanding the factors related to the disclosure process can help to inform prevention efforts. Using exploratory in-depth interviews, this qualitative study examines the disclosure process among a sample of twenty HIV-positive Black gay and bisexual men (mean age = 40) recruited through a non-profit health centre in a mid-western city in the USA. Data were analysed using a thematic analysis approach with HIV-disclosure as an a priori sensitising concept. Fears of stigma and secondary disclosure within social networks were critical barriers to talking about HIV with sexual partners and disclosure decisions involved a complex process centred on three primary themes: degree of sexual risk, partner type and perceived partner trustworthiness. The unique combinations of these contextual factors resulted in increased or decreased likelihood of disclosure. A conceptual model explicating a potential process by which these contextual factors influence disclosure decisions is presented.

Criminalization of HIV Exposure: A Review of Empirical Studies in the United States

This review of literature identifies and describes US empirical studies on the criminalization of HIV exposure, examines findings on key questions about these laws, highlights knowledge gaps, and sets a course for future research. Studies published between 1990 and 2014 were identified through key word searches of relevant electronic databases and discussions with experts. Twenty-five empirical studies were identified. Sixteen of these studies used quantitative methods with more than half of these being cross-sectional survey studies. Study samples included male and female HIV-positive persons, HIV-positive and -negative men who have sex with men, public health personnel, and medical providers. Research questions addressed awareness of and attitudes toward HIV exposure laws, potential influences of these laws on seropositive status disclosure for persons living with HIV, HIV testing for HIV-negative persons, safer sex practices for both groups, and associations between HIV exposure laws and HIV-related stigma. Surveys of the laws and studies of enforcement practices were also conducted. Attention should be shifted from examining attitudes about these laws to exploring their potential influence on public health practices and behaviors related to the HIV continuum of care. Studies examining enforcement and prosecution practices are also needed. Adapting a theoretical framework in future research may be useful in better understanding the influence of HIV exposure laws on HIV risk behaviors.

Effect of nondisclosure of HIV status in sexual health clinics on unlinked anonymous HIV prevalence estimates in England, 2005-2009

OBJECTIVES

To assess the extent of nondisclosure of known HIV status among sexual health clinic attendees and to quantify the impact of nondisclosure on estimates of undiagnosed HIV prevalence and of the proportion of patients remaining undiagnosed on leaving the clinic.

METHODS

Serum samples from the unlinked anonymous survey of clinic attendees' archive were tested for antiretrovirals. Estimates of undiagnosed HIV were adjusted using the findings.

RESULTS

Antiretrovirals were detected in 27% of samples taken from 'previously undiagnosed' attendees, who did not have an HIV test but were HIV positive as detected by unlinked anonymous testing, indicating nondisclosure; 24% of such samples from MSM had antiretrovirals present compared with 32% of heterosexual men and women. Antiretrovirals were detected in 33% of samples from London clinics and in 21% from non-London clinics. Following adjustment, the estimated prevalence of undiagnosed HIV decreased nonsignificantly from 3.04% (95% confidence interval 2.71-3.41) to 2.66% (2.35-3.01) among men who have sex with men (MSM), 0.31% (0.26-0.37) to 0.30% (0.25-0.36) in heterosexual men and 0.40% (0.35-0.46) to 0.37% (0.32-0.43) in women; 7% of MSM who do not have an HIV test at a clinic visit will be infected with HIV and remain unaware of their infection.

CONCLUSION

Nondisclosure of HIV status to healthcare professionals occurs among clinic attendees. Adjustment for nondisclosure results in a small, nonsignificant decrease in the prevalence of undiagnosed HIV estimated from the unlinked anonymous survey in sexual health clinics. Testing the population of MSM not having an HIV test remains a priority as levels of undiagnosed HIV are high.

Keeping confidence: HIV and the criminal law from HIV service providers' perspectives

We present qualitative research findings about how perceptions of criminal prosecutions for the transmission of HIV interact with the provision of high-quality HIV health and social care in England and Wales. Seven focus groups were undertaken with a total of 75 diverse professionals working in clinical and community-based services for people with HIV. Participants' understanding of the law in this area was varied, with many knowing the basic requirements for a prosecution, yet lacking confidence in the best way to communicate key details with those using their service. Prosecutions for HIV transmission have influenced, and in some instances, disrupted the provision of HIV services, creating ambivalence and concern among many providers about their new role as providers of legal information. The way that participants approached the topic with service users was influenced by their personal views on individual and shared responsibility for health, their concerns about professional liability and their degree of trust in non-coercive health promotion approaches to managing public health. These findings reveal an underlying ambivalence among many providers about how they regard the interface between criminal law, coercion and public health. It is also apparent that in most HIV service environments, meaningful exploration of practical ethical issues is relatively rare. The data presented here will additionally be of use to managers and providers of HIV services in order that they can provide consistent and confident support and advice to people with HIV.

Facilitators and Barriers to HIV Status Disclosure Among HIV-positive MSM Age 50 and Older

OBJECTIVE

Most HIV-positive men who have sex with men (MSM) ages 50 and older feel a responsibility to protect their sex partners from HIV transmission risk. For some, this is enacted through HIV disclosure, for others, this is realized through reduced risk behaviors.

METHODS

To examine this, we analyzed interviews of 23 HIV-positive MSM ages 50 and older.

RESULTS

We identified several contextual, relational, and psychosocial factors that served as either barriers or facilitators to HIV disclosure.

CONCLUSIONS

Our findings suggest HIV status disclosure is multifaceted and continues to impact sexual communication in the lives of MSM as they enter middle age.

HIV criminal prosecutions and public health: an examination of the empirical research

OBJECTIVES

To review the extant literature on HIV criminal laws, and to determine the impact of these laws on public health practice.

METHODS

The available research on this topic was obtained and reviewed.

RESULTS

The extant literature addressed three main topics: people's awareness of HIV criminal laws; people's perceptions of HIV criminal laws; and the potential effects of HIV criminal laws on people's sexual, HIV-status disclosure and healthcare-seeking practices. Within these categories, the literature demonstrated a high level of awareness of HIV criminal laws, but a poor comprehension of these laws. For perceptions, on the whole, the quantitative research identified support for, while the qualitative literature indicated opposition to, these laws. Lastly, the behavioural effects of HIV criminal laws appear to be complex and non-linear.

CONCLUSIONS

A review of the extant literature from a public health perspective leads to the conclusion that HIV criminal laws undermine public health.

Charges for criminal exposure to HIV and aggravated prostitution filed in the Nashville, Tennessee Prosecutorial Region 2000-2010

This paper examines comprehensive data on arrests for HIV-specific crimes within a single jurisdiction, the Nashville Tennessee prosecutorial region, over 11 years. There were 25 arrests for HIV exposure and 27 for aggravated prostitution. Eleven of the arrests for HIV exposure involved nonsexual behaviors; none alleged transmission. Sixteen of the arrests for HIV exposure involved sexual behavior; three alleged transmission. Aggravated prostitution cases (i.e. prostitution while knowing one has HIV) often involved solicitation of oral sex; none alleged transmission. Maximum sentences for HIV-specific crimes ranged from 5 to 8 years. We conclude that enforcement of US HIV-specific laws is underestimated. Fifty-two arrests over 11 years were recorded in one jurisdiction. Over half of the arrests involved behaviors posing minimal or no HIV transmission risk. Despite concerns about malicious, intentional HIV transmission, no cases alleged malice or intention.

Criminalization of HIV transmission and exposure: research and policy agenda

More than half of US jurisdictions have laws criminalizing knowing exposure to or transmission of HIV, yet little evidence supports these laws' effectiveness in reducing HIV incidence. These laws may undermine prevention efforts outlined in the US National HIV/AIDS Strategy, in which the United States has invested substantial federal funds. Future research should include studies of (1) the impact of US HIV exposure laws on public health systems and practices; (2) enforcement of these laws, including arrests, prosecutions, convictions, and sentencing; (3) alternatives to HIV exposure laws; and (4) direct and opportunity costs of enforcement. Policy efforts to mitigate potential negative impacts of these laws could include developing prosecutorial guidelines, modernized statutes, and model public health policies and protocols.

New Jersey's HIV exposure law and the HIV-related attitudes, beliefs, and sexual and seropositive status disclosure behaviors of persons living with HIV

OBJECTIVES

We explored associations between awareness of New Jersey's HIV exposure law and the HIV-related attitudes, beliefs, and sexual and seropositive status disclosure behaviors of HIV-positive persons.

METHODS

A statewide convenience sample (n = 479) completed anonymous written surveys during 2010. We recruited participants through networks of community-based organizations in the state's 9 health sectors. The survey assessed participants' awareness of New Jersey's HIV exposure law, their sexual and serostatus disclosure behavior in the past year, and their HIV-related attitudes and beliefs. We compared responses of participants who were and were not aware of the law through univariate analyses.

RESULTS

Fifty-one percent of participants knew about the HIV exposure law. This awareness was not associated with increased sexual abstinence, condom use with most recent partner, or seropositive status disclosure. Contrary to hypotheses, persons who were unaware of the law experienced greater stigma and were less comfortable with positive serostatus disclosure.

CONCLUSIONS

Criminializing nondisclosure of HIV serostatus does not reduce sexual risk behavior. Although the laws do not appear to increase stigma, they are also not likely to reduce HIV transmission.

A quantitative study of Michigan's criminal HIV exposure law

The objectives of the project were (1) to determine the extent to which HIV-positive persons living in Michigan were aware of and understood Michigan's criminal HIV exposure law, (2) to examine whether awareness of the law was associated with seropositive status disclosure to prospective sex partners, and, (3) to examine whether awareness of the law was associated with potential negative effects of the law on persons living with HIV (PLWH) including heightened HIV-related stigma, perceived societal hostility toward PLWH, and perceived need to conceal one's HIV infection. The study design was cross-sectional. A statewide sample of 384 PLWH in Michigan completed anonymous pen and paper surveys in 1 of 25 data collection sessions. A majority of participants were aware of Michigan's HIV exposure law. Awareness of the law was not associated with increased seropositive status disclosure to all prospective sex partners, decreased HIV transmission risk behavior, or increased perceived responsibility for HIV transmission prevention. However, awareness of the law was significantly associated with disclosure to a greater proportion of sex partners prior to respondents' first sexual interaction with that partner. Awareness of the law was not associated with increased HIV-related stigma, perceived societal hostility toward PLWH, or decreased comfort with seropositive status disclosure. Evidence of an effect of Michigan's HIV exposure law on seropositive status disclosure was mixed. Further research is needed to examine the various forms of HIV exposure laws among diverse groups of persons living with or at increased risk of acquiring HIV.

The problem of "significant risk": exploring the public health impact of criminalizing HIV non-disclosure

Using criminal law powers to respond to people living with HIV (PHAs) who expose sexual partners to HIV or transmit the virus to them is a prominent global HIV public policy issue. While there are widespread concerns about the public health impact of HIV-related criminalization, the social science literature on the topic is limited. This article responds to that gap in knowledge by reporting on the results of qualitative research conducted with service providers and PHAs in Canada. The article draws on a studies in the social organization of knowledge perspective and insights from critical criminology and work on the "medico-legal borderland." It investigates the role played by the legal concept of "significant risk" in coordinating criminal law governance and its interface with public health and HIV prevention. In doing so, the article emphasizes that exploring the public health impact of criminalization must move past the criminal law--PHA dyad to address broader social and institutional processes relevant to HIV prevention. Drawing on individual and focus group interviews, this article explores how criminal law governance shapes the activities of providers engaged in HIV prevention counseling, conceptualized as a complex of activities linking clinicians, public health officials, front-line counselors, PHAs, and others. It emphasizes three key findings: (1) the concept of significant risk poses serious problems to risk communication in HIV counseling and contributes to contradictory advice about disclosure obligations; (2) criminalization discourages PHAs' openness about HIV non-disclosure in counseling relationships; and (3) the recontextualization of public health interpretations of significant risk in criminal proceedings can intensify criminalization.

Facilitating HIV disclosure across diverse settings: a review

HIV status disclosure is central to debates about HIV because of its potential for HIV prevention and its links to privacy and confidentiality as human-rights issues. Our review of the HIV-disclosure literature found that few people keep their status completely secret; disclosure tends to be iterative and to be higher in high-income countries; gender shapes disclosure motivations and reactions; involuntary disclosure and low levels of partner disclosure highlight the difficulties faced by health workers; the meaning and process of disclosure differ across settings; stigmatization increases fears of disclosure; and the ethical dilemmas resulting from competing values concerning confidentiality influence the extent to which disclosure can be facilitated. Our results suggest that structural changes, including making more services available, could facilitate HIV disclosure as much as individual approaches and counseling do.