410.003 Accelerated HIV Intervention Program, Addressing the Potential for Recalcitrant Transmission of HIV in Texas

Policy Number 410.003
Effective Date August 7, 2000
Revision Date November 14, 2001
Approval Authority TB/HIV/STD Section Director

1.0 Purpose

This policy establishes the Accelerated HIV Intervention Program, a program developed by the TB/HIV/STD Section (Section) to address the public health concerns of potential HIV transmission to unsuspecting persons by an individual who is known to have HIV. Any HIV positive individual found to be practicing recurrent behaviors which are known to transmit the virus and who engages in those behaviors with limited regard for the health of another person is considered a threat to public health.

This policy is directed to managers of STD programs located in Texas Department of State Health Services (DSHS) regional offices and in major local health departments or districts funded through DSHS. The Accelerated HIV Intervention Program (program) is designed to assist STD programs in developing intervention strategies for counseling and managing HIV positive clients who are considered to be a threat to public health. The policy also provides information on two additional control measures (public health orders and court orders) which may be used to intervene in the transmission of the disease. The specific processes for issuing public health orders and court orders exist in V.T.C.A. Health and Safety Code, Chapter 81.

It is not the intent of this policy for STD programs in regional and local health departments to establish elaborate systems to detect and track incidents which may be seen as markers for continued unsafe behaviors. Instead, this policy is intended to guide STD programs when they are made aware that an individual represents a potential public health threat. They may become aware of these situations through interaction with their own clients, or when other providers consult the STD program.

Ultimately, the objective of the Accelerated Intervention Program is to provide effective behavioral interventions to these individuals, reducing or eliminating the potential for further transmission. The application of public health orders should be viewed as a last resort to motivate the individual to participate in behavioral modification programs.

Finally, while this policy is written specifically for HIV transmission, other STDs may also be knowingly transmitted. In some cases, the transmission of an STD other than HIV may also have catastrophic consequences (such as the willful transmission of syphilis to a pregnant woman). Though not specific to other STDs, this policy should be used as a guide for managing these situations as well.

The success of this program relies on collaboration between local and regional public health offices, the Section, and appropriate mental health professionals and substance abuse treatment facilities.

2.0 Background

In Texas, facilities conducting HIV testing must offer positive test result counseling to any individual who tests positive for HIV (Health and Safety Code 81.109). Counseling is to be delivered in accordance with the HIV/STD Guidelines developed by the Section. No further interventions are required; however, quality counseling should identify whether continued behavior management and interventions may be necessary to support behavior changes in an individual in order to reduce the potential for disease transmission.

An individual who is infected with HIV presents a threat to public health when he or she continues to engage in behaviors which are known to transmit HIV from one person to another. Recalcitrance occurs in cases where attempts to stop an individual from transmitting a communicable disease fail, and documentation substantiates continued involvement in unsafe behaviors. Texas law (V.T.C.A. Health and Safety Code §81.083) gives the DSHS, or a health authority, the authority to apply public health orders to a recalcitrant individual when there is reasonable cause to believe that the individual presents a threat to public health and attempts to intervene in the transmission of the disease have failed.

3.0 Authority

V.T.C.A., Health and Safety Code (HSC) §81.046, Confidentiality; §81.051, Partner Notification Programs, HIV Infection; §81.061, Investigation; §81.082, Administration of Control Measures; §81.083, Application of Control Measures to Individual; §81.151, Application for Court Order.

25 Texas Administrative Code, §97.8, General Control Measures for Reportable Diseases.

4.0 Definitions as Applied to Section Policy

Health Care Professional – A person whose vocation or profession is related to the maintenance of the health of another person and whose duties require a specified amount of formal education and may require a special examination, certificate or license. Membership in a regional or national association may also be required. The term does not include HIV counselors or unlicensed staff working for STD programs.

Public Health Threat – An HIV infected individual who practices behaviors which place other persons at risk of acquiring HIV. This includes behavior that is known to transmit HIV, and past behaviors or statements that show a credible intent to transmit HIV.

Recalcitrant – An infected individual who, after receiving intensive behavioral counseling, continues to engage in behaviors known to transmit HIV.

5.0 Positive Test Result Counseling

In Texas, any individual who tests positive for HIV must be offered the opportunity to receive face-to-face positive test result counseling. Staff of HIV and/or STD programs need to document and discuss with their supervisor any problems encountered during positive test result counseling sessions. Staff will also discuss with their supervisor the need to perform additional follow-up counseling on any client.

HIV counseling facilities will refer all clients who do not return to receive their positive test results and counseling in accordance with the DSHS HIV/STD Guidelines, C., Follow-Up for DSHS Contractor’s HIV Positive Clients Who Fail to Return for Results to the local or regional health department STD program. The supervisor will also contact the local or regional STD program when it has been determined that the post-test counseling provided to the client was inadequate or incomplete (e.g. a client receives the test result but fails to stay for counseling). The HIV counseling facility must maintain the lab result and accompanying documentation in accordance with applicable retention schedules.

The STD program receiving a referral from an HIV counseling facility will initiate an assessment within 24 hours of receiving the referral. The assessment and follow-up will be performed by the STD program consistent with the DSHS HIV/STD Guidelines, Section G., Performance Guidelines for Disease Intervention Specialists.

6.0 Accelerated HIV Intervention Program

In an attempt to address and control the willful transmission of HIV infection in Texas, regional and local health departments in collaboration with the Section will undertake reasonable efforts to (1) respond to referrals from health care professionals and HIV and/or STD programs that identify HIV positive persons who may pose a threat to public health, and (2) apply the control measures set out in the Accelerated HIV Intervention Program.

The Accelerated HIV Intervention Program relies on complete and factual documentation, collaboration between city/county and regional health department offices, the Section, and mental health professionals and substance abuse treatment facilities; and the ability of the STD program to:

  1. investigate circumstances related to intentional or knowing disease transmission;
  2. maintain adequate documentation on all potential public health threat referrals received and the health department’s follow-up activities relating to each referral;
  3. identify and assess the HIV positive client to determine if the client’s behavior presents a threat to public health;
  4. provide client-centered HIV prevention counseling, and
  5. provide linkages to local community service providers and health care professionals, specifically mental health professionals and substance abuse treatment facilities.

The manager of the STD program is responsible for determining whom on their staff will assess referrals of public health threats, and who on their staff or in their community will be responsible for delivering the counseling aspects of the program. The STD manager will assign the assessment function to STD staff who have experience working with HIV positive persons in high risk environments and who are familiar with the service provider referral system established in their communities.

6.1 Forms

Forms have been created specifically for the Accelerated HIV Intervention Program to document referrals of individuals who may present a potential threat to public health and to track the intervention activities provided to those individuals. Completed, these forms summarize the actions taken by public health workers and do not record the specific discussions or events which take place during delivery of the Accelerated HIV Intervention Program.

To avoid duplication of existing forms used by public health workers, STD programs will use existing field investigation forms found in the DSHS HIV/STD Guidelines to document detailed activities, discussions, and outcomes. Together these forms will constitute a case file.

6.2 Inter-agency communication/service agreement

In order to conduct follow-up on clients who are given referrals to other service providers, it may be necessary to solicit the cooperation of other client-based service organizations including community-based service organizations. This is especially relevant when a client accesses substance abuse or mental illness treatment facilities. Many of these facilities operate under confidentiality guidelines that may specifically relate to HIV confidentiality laws or relate to more generalized medical records confidentiality laws. Regardless of what confidentiality laws apply to these organizations it is important for STD programs to enter into quality service organization agreements (QSOA) with these organizations. QSOAs should be written to facilitate client access to care and services, and to allow the referring STD program access to client information. STD programs should coordinate the development of QSOAs with appropriate legal counsel.

Even with a QSOA in place, the Section recommends obtaining the client’s written permission before accessing the client’s medical record, treatment record, or service record. The client’s written permission should be obtained during the initial Accelerated HIV Intervention Counseling session and during each subsequent encounter when a referral is provided to the client. For this reason, STD programs should use the L-29 Referral Form found in the HIV/STD Guidelines. A QSOA alone may only allow the STD program generalized information on the client such as whether or not the client is receiving care or service. A release form signed by the client should allow the STD program to establish open communication with the provider in order to gather information on what types of services or treatments the client is receiving.

7.0 Responding to Referrals of Persons who Represent a Potential Threat to Public Health

STD programs will accept referrals from health care professionals, HIV counselors, and staff in STD clinics of HIV positive clients who display any of the specific characteristics in this policy. The STD program will document all referrals according to this policy and the DSHS HIV/STD Guidelines. The manager of the STD program is responsible for reviewing all referrals over which the city/county or regional health department STD program has jurisdiction or for routing the referral to the appropriate STD program that has jurisdiction.

The Section does not recommend that STD programs respond to referrals received from persons other than HIV and/or STD programs or health care professionals. However, should the STD program accept referrals from other sources than those specified, special care must be taken to verify facts contained in the referral prior to initiating contact with the referred client.

In areas of Texas where access to city/county health departments is limited, referrals received by the Section will automatically be forwarded to the appropriate local or regional public health office for assessment.

Referrals, records, and information pertaining to disease investigations are confidential under V.T.C.A. Health and Safety Code §§81.046 and 81.103. Information regarding the source of the referral and the information contained in the referral will not be disclosed to the HIV positive client under investigation or to anyone outside of the public health system, unless authorized by law.

7.1 Characteristics that will trigger an STD program assessment

Referrals received by a STD program of HIV positive clients with any one of these characteristics occurring after receiving at least one HIV positive test result counseling session will trigger an assessment:

  1. is diagnosed by a health care professional as having a new STD infection;
  2. is named as a contact during a sexually transmitted disease partner elicitation session;
  3. has donated blood, semen, or other body fluid, organ, or tissue;
  4. is pregnant (see section entitled “ASSESSING PREGNANCY”);
  5. has threatened to expose others to the HIV infection, or
  6. has engaged in anal, vaginal, or oral sex or has shared contaminated hypodermic needles and has failed to either inform partner(s) of his/her HIV infected status, or take reasonable precautions to prevent transmission.

7.2 Completing a referral

When a referral is made, the STD program receiving the referral will gather the following information on the Public Health Intervention Referral form (HIV/STD Form No. 410.003-A):

  1. the name, address, and telephone number of the person filing the referral;
  2. the name, address and/or telephone number of the individual being referred (client);
  3. a description of the client’s behaviors (see “trigger characteristics” above)
    1. where and when the behavior occurred,
    2. how the referring party became aware of the trigger, and
    3. additional information to support the allegations; and
  4. documentation of HIV infection. Actual HIV infection status must be verified. To verify that the client has AIDS or HIV, one of the following must be present:
    1. the client's name is in the Texas HIV/AIDS reporting system, or
    2. the results of a positive antibody/antigen test or a diagnosis of AIDS consistent with CDC criteria are made available by the health care provider or HIV and/or STD program.

7.3 Record search

Within 24 hours of receiving the referral the STD program will:

  1. conduct a record search to verify HIV infection,
  2. determine if positive test result counseling was provided and document the date of the counseling,
  3. attempt to confirm the trigger characteristic, and
  4. complete the initial assessment (HIV/STD Form No. 410.003-A).

7.4 Assessing the referral

All referrals received from HIV and/or STD programs and health care professionals will be assessed by the STD program receiving the referral using form 410.003-A. Referrals are assessed to determine if the referred behavior is consistent with those behaviors known to transmit HIV, and whether without intervention the potential for transmission to an uninfected person exists. Following the assessment, the STD program manager will determine whether to close the case, initiate accelerated HIV prevention counseling, or to request the local health authority issue a public health order (see subsection entitled “Identifying characteristics which may lead to a public health order case review”). No action will be initiated on referrals that contain insufficient information.

7.5 Assessing pregnancy

An HIV positive female becoming pregnant does not, in and of itself, constitute a public health risk. However, pregnancy is retained as a trigger characteristic for investigation because of the high probability that unprotected penile-vaginal intercourse has occurred and because prenatal intervention may significantly reduce vertical transmission. Any follow-up conducted on pregnant females will be used as an opportunity to assure that all appropriate referrals for prenatal care are made available. Assessment of behavior resulting in pregnancy will be handled with the utmost sensitivity.

Assessments conducted on referred pregnancies will take into account the context of the behavior. In addition to the assessment steps already listed, pregnancy assessments will include:

  • gathering information from the health care provider about the client’s access to prenatal care and HIV prophylaxis. Upon initial contact with the client, the STD program will assure that the client has received information necessary for her to make an informed decision regarding prenatal care and intervention.
  • researching the means of insemination. In instances when medical records indicate pregnancy occurred as a result of artificial insemination, the case is to be closed without further investigation.
  • determining if the client’s partner had knowledge of the client’s HIV status. The case is to be closed when information indicates the male partner(s) was aware of the client’s HIV status prior to having unprotected sexual intercourse with the client. However, risk reduction counseling may need to be conducted with the male partner.

7.6 Determining next steps

Based upon the results of the assessment, the STD program manager in conjunction with appropriate local health department staff or the local health officer will review the case file and any other pertinent information to decide if a potential health threat to others exists.

  • When unable to verify the client has HIV, the case is to be closed without further investigation.
  • When unable to verify that an HIV positive client has engaged in behaviors known to transmit the disease or has expressed the intent to transmit the disease, the STD program may close the case unless further information is obtained.
  • When positive test result counseling cannot be verified to have been performed after the client tested positive, a positive test result counseling session will be conducted and documented.
  • When positive test result counseling can be verified then accelerated HIV prevention counseling must take place.

8.0 Selecting the Appropriate Control Measure

The results of the investigation will determine the type of control measure to be initiated. The control measures which may be applied to a public health threat are:

  1. accelerated HIV prevention counseling,
  2. public health orders, and
  3. court orders.

8.1 Accelerated HIV prevention counseling

The Section strongly recommends those HIV positive clients who appear to present a threat to public health be given the opportunity to participate in accelerated HIV prevention counseling. The STD program will determine the appropriate level of counseling that will be delivered and whether the counseling will be provided by a disease intervention specialist, an HIV counselor in the community, a mental health professional, or by a substance abuse treatment professional. When counseling is provided by the STD program or an HIV counselor, it is important to also consider the appropriateness of providing a referral to a mental health professional and/or to a substance abuse treatment facility.

Accelerated HIV prevention counseling is based upon current prevention counseling and partner elicitation (PCPE) models and will be conducted in accordance with the HIV/STD Guidelines and with techniques taught through PCPE training courses. In the course of providing HIV prevention counseling, the person delivering the counseling will:

  1. perform partner elicitation and/or notification according to the HIV/STD Guidelines, Section A, Prevention Counseling Guidelines;
  2. develop a risk reduction plan with the client;
  3. provide appropriate referrals and make appointments when necessary on behalf of the client to;
    1. medical and social services,
    2. mental health services,
    3. substance abuse treatment services, and
    4. prevention case management services, early intervention programs, and/or clinical/psycho-social case management programs;
  4. document all referrals on form L-29;
  5. obtain the client’s signature on the client acknowledgment form (HIV/STD 410.003-B);
  6. obtain the client’s signature on referral forms (form L-29);
  7. document the discussions of the session according to standard protocol and summarize the sessions in the Public Health Intervention Referral form HIV/STD 410.003-A, and
  8. schedule and perform a follow-up visit within two weeks of the first visit.

When additional counseling sessions are deemed necessary, the follow-up counseling sessions will be delivered on a minimum of two week intervals following the initial two sessions. Follow-up counseling sessions may be conducted more frequently to meet individual circumstances. The follow-up visits will focus on assessing the success of the preceding counseling sessions and will emphasize:

  1. reinforcing and updating the risk reduction plan developed during the preceding counseling session;
  2. providing additional referrals and reviewing previously set appointments;
  3. discussing new issues or unresolved issues, and
  4. gaining the client’s continued commitment to changing behaviors.

Determination must be made whether to continue with accelerated HIV prevention counseling, issue a public health order, or close the case file. When the client has progressed sufficiently, the person who delivered the counseling must discuss closing the case with the STD program manager. To close a case, the STD program manager must review the case file to determine that the client has accessed the referral system and has demonstrated a commitment to changing behaviors.

A client meets the definition of recalcitrance when the client resists participating in accelerated HIV prevention counseling and is unwilling to change his/her behaviors. Texas law (V.T.C.A. Health and Safety Code §81.083) gives local health authorities the option to apply public health orders to a recalcitrant client when attempts to intervene in the transmission of the disease have failed. When the client is determined to be recalcitrant, the STD program manager may decide to initiate a public health order case review.

8.2 Identifying characteristics which may lead to a public health order case review

The STD program manager determines when a public health order case review is initiated and may wish to initiate a case review after at least one accelerated HIV prevention counseling session has been attempted and the client:

  1. presents to a health care professional with a new STD infection,
  2. is named as a contact during a sexually transmitted disease partner elicitation session,
  3. has donated blood, semen, or other body fluid, organ, or tissue,
  4. is pregnant,
  5. has threatened to expose others to the HIV infection, or
  6. has engaged in anal, vaginal, or oral sex or has shared needles and has failed to either inform partner(s) of his/her HIV infected status, or take reasonable precautions to prevent transmission.

In addition, identification of either one of the two characteristics listed below will automatically lead to a public health order case review.

  • Refusal to participate in accelerated HIV prevention counseling.
  • Resistance to changing behaviors.

8.3 Public health order case review

The purpose of a public health order case review is to ensure those public health officials at the state and local levels are fully informed of the particulars of the case before a public health order is issued. A public health order should only be considered when all other reasonable attempts to persuade the client to attempt behavior change have failed. The STD program is responsible for coordinating the review with local or regional health officials and with the Section. Coordination with the Section is made by contacting the appropriate team supervisor in the Section.

The Section’s role in the case review is to gather information on the STD program’s investigation process, provide the STD program with feedback on the investigation process and to assist in developing an action plan. No case files are to be copied and forwarded to the Section for review unless requested. Verbal information shared via teleconference or in a face-to-face case review meeting is sufficient.

The Section is responsible for alerting appropriate state officials should the need arise and therefore must be fully informed of the investigation. It is not the Section’s responsibility nor the responsibility of DSHS to issue the public health order. The decision to proceed with a public health order is that of the local/regional health department and the local health authority.

The STD program decides when to inform the local health authority about the case. The public health order must be issued through the local health authority and only after the case review has been conducted. It is advisable for the STD program manager to inform their appropriate legal counsel of the decision to issue a public health order. Legal counsel may be used to assist the program and the local health authority in drafting the language of the order (see form 410.003-C, “Model Public Health Order”).

8.4 Issuing a public health order

A public health order is a formal written notice issued by a local health authority and delivered to the recalcitrant client. The order warns the client that failure to cease and desist engaging in behaviors that jeopardize the health of others may prompt the local health authority to request the district court to issue an order against the client. The public health order will:

  1. be in writing, (except in urgent circumstances-delivered orally, followed by a written statement within three days) specific to the client, and identify the behavior that poses a health threat to others;
  2. require the client to cooperate with the local or regional health department in efforts to prevent further transmission of the HIV infection;
  3. require the client to participate in HIV education and/or counseling, and may require the client to accept referrals to health and social service programs or, to enroll in mental health counseling or substance abuse treatment programs;
  4. state the consequences for failing to comply with the order, and
  5. be delivered by registered mail, return receipt requested, or personally, by a representative of the department or local health department.

When the local health authority chooses to mail an order, the STD program should conduct a follow-up visit after the order has been mailed if the client fails to respond within the time specified or fails to keep scheduled appointments. When performing a follow-up visit, it is important to reiterate to the client the severity of the order and the repercussions for failing to comply with the order. The person performing the follow-up visit will ask the client to sign a copy of the public health order and the client acknowledgment form. The client acknowledgment form provides the STD program with documentation that the client has received verbal instruction related to the public health order and understands the repercussions for failing to comply with the order. Refusal by the client to sign either the public health order or the acknowledgment form will be documented in the case file.

A second public health order may be issued for a client who fails to respond within the time designated by the first order or the STD program may decide to move toward requesting local health authority have the district court to issue an order. The STD program will follow up on the second public health order in the same manner as the first.

8.5 Court orders

Issuance of a public health order must precede a court order. Court orders are sought only after public health authority interventions have failed. A court order should be considered a last resort to be used only in the most serious cases.

The local health authority has the power to request a court to issue an order demanding that a client stop engaging in behaviors which are placing public health in jeopardy (HSC §81.151 - Court Order). Prior to referring the case to the local health authority, the STD program manager must review the documentation to make sure it is complete and accurate, that accelerated intervention has been attempted, and outlines the reasons why intervention activities have been unsuccessful. Any rendering of a case file to a local health authority for further action must be signed and routed through the appropriate local channels. A copy of the court order must be mailed to the Section. For more information on court orders refer to V.T.C.A. Health and Safety Code, Chapter 81, Subchapter E., Control.

9.0 Handling Clients Who Relocate

As long as the client resides in the state of Texas, the case file will continue to be investigated. Local and regional STD programs are expected to directly coordinate the investigation of cases which cross geographic boundaries.
Public health orders issued by a local health authority do not transfer when a client under investigation moves outside the jurisdiction of the local health authority. When the client moves outside the area in which the order was issued, the local or regional STD program will need to request a new order from the health authority responsible for the area in which the client now resides.

Court orders apply regardless of where the client named in the order relocates. Once a court order is issued, it does not need to be reissued when the client named in the order relocates.

New case files do not need to be opened when the client relocates within Texas. STD programs may use the existing transferred records to support their request to have the local health authority issue a public health order or to support the health authority’s petition for a court order.

When the client relocates out of state, the local or regional STD program responsible for the investigation will notify the Section’s interstate communication control records coordinator. DSHS will follow the established procedure for transferring interstate STD records. Local health departments located in Houston and Dallas are responsible for their own interstate notifications.

The Section’s interstate communication control records coordinator will inform the responsible STD program when the interstate notification occurred. Once interstate notification has occurred, the case file can be closed and retained according to the established retention period.

10.0 Additional Referrals of Recalcitrant Behaviors

When a STD program receives a referral that a client who previously received intensive prevention counseling is again engaging in unsafe behaviors, the STD program manager has the discretion to reopen the case file or to assess the referral as a new referral.

All referrals of noncompliant behavior will be documented according to protocols of this policy.

11.0 Record Retention

Investigation records will be retained by the local or regional program according to record retention protocols and are not considered to be public information under Chapter 552, Government Code. Records pertaining to disease reports and investigations may not be released or made public on subpoena or otherwise except as provided by Health and Safety Code §81.046, Subsections (c) and (d).

12.0 Additional Resources

Assessing Referrals flow chart
Control Measures flow chart
Form 410.003A - Public Health Intervention Referral
Form 410.003B - Model Client Acknowledgment Form
Form 410.003C - Model Public Health Warning Notice

13.0 Revision History

Date Action Section
9/1/2017 Changed "TB/HIV/STD Unit" to "TB/HIV/STD Section" to reflect new program designation -
10/6/2014 Converted format (Word to HTML) -
Created standalone Word versions of forms 410.003A, 410.003B, 410.003C 12.0
1/23/2003 Converted format (WordPerfect to Word) -