Sexual transmission of HIV and the law: an Australian medical consensus statement

Boyd, Mark; Cooper, David; Crock, Elizabeth A; Crooks, Levinia; Giles, Michelle L; Grulich, Andrew; Lewin, Sharon R; Nolan, David; Yarwood, Trent

doi:10.5694/mja16.00934

ARTICLE
AUTHORS
REFERENCES

Topics

Infectious diseases

Ethics and law

Abstract

Introduction: Criminal cases involving human immunodeficiency virus transmission or exposure require that courts correctly comprehend the rapidly evolving science of HIV transmission and the impact of an HIV diagnosis. This consensus statement, written by leading HIV clinicians and scientists, provides current scientific evidence to facilitate just outcomes in Australian criminal cases involving HIV.

Main recommendations: Caution should be exercised when considering charges or prosecutions regarding HIV transmission or exposure because:

Scientific evidence shows that the risk of HIV transmission during sex between partners of different HIV serostatus can be low, negligible or too low to quantify, even when the HIV-positive partner is not taking effective antiretroviral therapy, depending on the nature of the sexual act, the viral load of the partner with HIV, and whether a condom or pre-exposure prophylaxis is employed to reduce risk.
The use of phylogenetic analysis in cases of suspected HIV transmission requires careful consideration of its limited probative value as evidence of causation of HIV infection, although such an approach may provide valuable information, particularly in relation to excluding HIV transmission between individuals.
Most people recently infected with HIV are able to commence simple treatment providing them a normal and healthy life expectancy, largely comparable with their HIV-negative peers. Among people who have been diagnosed and are receiving treatment, HIV is rarely life threatening. People with HIV can conceive children with negligible risk to their partner and low risk to their child.

Changes in management as result of the consensus statement: Given the limited risk of HIV transmission per sexual act and the limited long term harms experienced by most people recently diagnosed with HIV, appropriate care should be taken before HIV prosecutions are pursued. Careful attention should be paid to the best scientific evidence on HIV risk and harms, with consideration given to alternatives to prosecution, including public health management.

1 Lyell McEwin Hospital, University of Adelaide, Adelaide, SA
2 Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine, Sydney, NSW
3 Kirby Institute, University of New South Wales, Sydney, NSW
4 Australian and New Zealand Association of Nurses in AIDS Care, Melbourne, VIC
5 La Trobe University, Melbourne, VIC
6 Monash University, Melbourne, VIC
7 Peter Doherty Institute for Infection and Immunity, University of Melbourne and Royal Melbourne Hospital, Melbourne, VIC
8 Royal Perth Hospital, Perth, WA
9 Cairns Hospital, Cairns, QLD

Correspondence: Levinia.Crooks@ashm.org.au

Acknowledgements:

On behalf of all the authors: for the full author list, see the Appendix at mja.com.au. Endorsed by the Australasian Society for Infectious Diseases (ASID) and the Australian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM).

Competing interests:

Mark Boyd receives grant funding and honoraria for preparation and delivery of educational materials from AbbVie, Merck, Gilead, Bristol-Myers Squibb, Janssen-Cilag and ViiV Healthcare. Levinia Crooks receives a fee from Gilead for sitting on their fellowship committee; the full fee is allocated to the ASHM International Gift Fund. Andrew Grulich has acted as an expert witness in legal cases concerning HIV transmission. Andrew Redmond is a board member of the HIV Foundation Queensland.

1. Woodroffe M. Criminal transmission of HIV in Australia. In: The criminalisation of HIV transmission in Australia: legality, morality and reality. Sydney: National Association of People Living with HIV of Australia, 2009: 60-73.
2. Cameron S. HIV, Crime and the law in Australia: Options for policy reform — a law reform advocacy kit. Sydney: Australian Federation of AIDS Organisations, 2011. https://www.afao.org.au/__data/assets/pdf_file/0018/4536/DP0211_HIV_Crime_and_the_Law.pdf (accessed Sept 2016).
3. Loutfy M, Tyndall M, Baril J-G, et al. Canadian consensus statement on HIV and its transmission in the context of criminal law. Can J Infect Dis Med Microbiol 2014; 25: 135-140.
4. Baggaley RF, Boily M-C, White RG, Alary M. Risk of HIV-1 transmission for parenteral exposure and blood transfusion: a systematic review and meta-analysis. AIDS 2006; 20: 805-812.
5. Cohen MS, Chen YQ, McCauley M, et al. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med 2011; 365: 493-505.
6. Rodger AJ, Cambiano V, Bruun T, et al. Sexual activity without condoms and risk of hiv transmission in serodifferent couples when the HIV-positive partner is using suppressive antiretroviral therapy. JAMA 2016; 316: 171-181.
7. Weller S, Davis K. Condom effectiveness in reducing heterosexual HIV transmission. Cochrane Database Syst Rev 2002; (1): CD003255.
8. Crosby R, Bounse S. Condom effectiveness: where are we now? Sex Health 2012; 9: 10-17.
9. National Institute of Allergy and Infectious Diseases. Workshop summary: Scientific evidence on condom effectiveness for sexually transmitted disease (STD) prevention. Bethesda, MD: NIAID, 2001.
10. Grant RM, Lama JR, Anderson PL, et al. Preexposure chemoprophylaxis for HIV prevention in men who have sex with men. N Engl J Med 2010; 363: 2587-2599.
11. McCormack S, Dunn DT, Desai M, et al. Pre-exposure prophylaxis to prevent the acquisition of HIV-1 infection (PROUD): effectiveness results from the pilot phase of a pragmatic open-label randomised trial. Lancet 2016; 387: 53-60.
12. Molina J-M, Capitant C, Spire B, et al. On-demand preexposure prophylaxis in men at high risk for HIV-1 infection. N Engl J Med 2015; 373: 2237-2246.
13. Baggaley RF, White RG, Boily MC. Systematic review of orogenital HIV 1 transmission probabilities. Int J Epidemiol 2008; 37: 1255-1265.
14. Supervie V, Viard J-P, Costagliola D, Breban R. Heterosexual risk of HIV transmission per sexual act under combined antiretroviral therapy: systematic review and Bayesian modeling. Clin Infect Dis Off Publ Infect Dis Soc Am 2014; 59: 115-122.
15. Boily M-C, Baggaley RF, Wang L, et al. Heterosexual risk of HIV-1 infection per sexual act: systematic review and meta-analysis of observational studies. Lancet Infect Dis 2009; 9: 118-129.
16. Rodger A, Cambiano V, Bruun T, et al. HIV transmission risk through condomless sex if HIV positive partner on suppressive ART: PARTNER study. In: Proceedings of the Conference on Retroviruses and Opportunistic Infections (CROI), 3–6 Mar 2014; Boston, MA. http://www.chip.dk/portals/0/files/CROI_2014_PARTNER_slides.pdf (accessed Sept 2016).
17. Baggaley RF, White RG, Boily M-C. HIV transmission risk through anal intercourse: systematic review, meta-analysis and implications for HIV prevention. Int J Epidemiol 2010; 39: 1048-1063.
18. Sexton J, Garnett G, Røttingen J-A. Metaanalysis and metaregression in interpreting study variability in the impact of sexually transmitted diseases on susceptibility to HIV infection. Sex Transm Dis 2005; 32: 351-357.
19. Kidd P. Phylogenetic analysis as expert evidence in HIV transmission prosecutions. HIV Aust 2016; 14: 21-23.
20. Poon AFY, Gustafson R, Daly P, et al. Near real-time monitoring of HIV transmission hotspots from routine HIV genotyping: an implementation case study. Lancet HIV 2016; 3: e231-e238.
21. Chen M, Ma Y, Yang C, et al. The combination of phylogenetic analysis with epidemiological and serological data to track HIV-1 transmission in a sexual transmission case. PLoS ONE 2015; 10: e011989.
22. Boyd MA. Improvements in antiretroviral therapy outcomes over calendar time. Curr Opin HIV AIDS 2009; 4: 194-199.
23. Thompson MA, Aberg JA, Hoy JF, et al. Antiretroviral treatment of adult HIV infection: 2012 recommendations of the International Antiviral Society-USA panel. JAMA 2012; 308: 387-402.
24. Antiretroviral Therapy Cohort Collaboration. Life expectancy of individuals on combination antiretroviral therapy in high-income countries: a collaborative analysis of 14 cohort studies. Lancet 2008; 372: 293-299.
25. Johnson LF, Mossong J, Dorrington RE, et al. Life expectancies of South African adults starting antiretroviral treatment: collaborative analysis of cohort studies. PLoS Med 2013; 10: e1001418.
26. Marmot M. Social determinants of health inequalities. Lancet 2005; 365: 1099-1104.
27. Samji H, Cescon A, Hogg RS, et al. Closing the Gap: increases in life expectancy among treated HIV-positive individuals in the United States and Canada. PLoS ONE 2013; 8: e81355.
28. Kirby Institute. HIV, viral hepatitis and sexually transmissible infections in Australia: Annual Surveillance Report 2015. Sydney: Kirby Institute, UNSW Australia, 2015. https://www.kirby.unsw.edu.au/sites/default/files/hiv/resources/2015%20Annual%20Surveillance%20Report%20of%20HIV,%20viral%20hepatitis,%20STIs.pdf (accessed Sept 2016).
29. Vernazza P, Hirschel B, Bernasconi E, Flepp M. Les personnes séropositives ne souffrant d’aucune autre MST et suivant un traitement antirétroviral efficace ne transmettent pas le VIH par voie sexuelle. Bull Méd Suisses 2008; 89: 165-169.
30. Townsend CL, Byrne L, Cortina-Borja M, et al. Earlier initiation of ART and further decline in mother-to-child HIV transmission rates, 2000–2011. AIDS 2014; 28: 1049-1057.
31. Grierson J, Pitts M, Koelmeyer R. HIV Futures Seven: the health and wellbeing of HIV positive people in Australia. Melbourne: Australian Research Centre in Sex, Health and Society, 2013.
32. Australian Federation of AIDS Organisations, National Association of People with HIV Australia. Next steps. http://hivnextsteps.org.au (accessed Sept 2016).
33. Department of Health. National guidelines for the management of people with HIV who place others at risk. Canberra: Department of Health, 2008. http://www.health.gov.au/internet/main/publishing.nsf/Content/phd-hiv-guideline-at-risk (accessed Sept 2016).

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Sexual transmission of HIV and the law: an Australian medical consensus statement

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