- aims to identify individuals who may be unaware of their HIV infection, so they may benefit from treatment and be provided support to affect sustained behaviour change thereby mitigating ongoing transmission of HIV.
- must not be associated with blaming the index case, and indeed, the identity of the index case must in most instances remain confidential.
- is a delicate task and if undertaken inexpertly or insensitively can alienate individuals (and communities) and cause additional anxiety and distress.
- will differ in every case, so each instance must include assessment of the biological, social, ethical and legal implications of the particular case.
- is only one facet of HIV prevention mechanisms, and plays a limited role when considered against other prevention measures including preventive education campaigns, voluntary HIV testing, distribution of condoms and safe drug injecting equipment, and the myriad laws and policies which support these and other preventive measures.
- must not undermine the constructive partnerships between communities at risk, health care professionals, government agencies and research bodies that have proven invaluable in minimising HIV transmission in Australia.
In all jurisdictions, medical practitioners (and sometimes other health care professionals) are tasked with identifying patients’ risk episodes and raising the importance of contact tracing. Patient and health care providers then discuss the most appropriate way to make contact with current and previous sexual partners. Generally, contact tracing may be conducted by the patient or health care worker, with delegation recommended to specialised contact tracing officers in certain circumstances, including instances when the health care worker is unable to undertake contact tracing due to time restrictions (see overview of contact tracing state based laws and guidelines below).
Those wishing to access expert assistance should contact their applicable health department in the first instance.
Choosing a method of advising contacts
The method of advising and counselling contacts about their exposure to HIV is chosen after taking into account the risk history, condition, sexual or social environment and motivation of the index case. The following strategies are available:
Patient (index case) referral
Specific instructions: The health care provider presents the index case with specific advice regarding which contacts to advise and the information to be imparted, including appropriate agencies for assessment and counselling. The index case personally notifies his/her contact(s). Many services provide contact letters (sample included in The Australasian Contact Tracing Manual) detailing the index case’s diagnosis and treatment, that the contact can take to the doctor of his/her choice.
Imparting skills: Patient referral requires a well-informed, motivated and self-confident index patient. If the index case fears embarrassment or reprisal by his/her contact(s), it may be helpful for a skilled counsellor to rehearse the notification with the index case. The advantages of role-playing are that information to be imparted can be confirmed and the index case can be taught to anticipate and respond to reactions by contacts. General counselling support can also be provided. If relying on patient referral, it is important to use follow-up consultations to confirm that the contacts have been advised and assessed adequately.
Either at the index patient’s request or at the suggestion of the health care provider, the provider may advise the contact(s) directly or recruit another agency (e.g. sexual health service, public health unit) to ensure that the contact(s) are assessed. To do so, the health care provider should have the explicit approval of the index case (check confidentiality requirements).
Provider referral may have the advantage of offering the index case a higher level of confidentiality. However, provider referral is more time- and resource-intensive. It is the contact tracing method of choice for certain situations and conditions, e.g. where patient referral has failed or when the index case fears a violent reaction. A combination of patient and provider referral is often used for the different contacts of one index case.
Based on extract from The Australasian Contact Tracing Manual, 3rd Edition1 (2006)
Overview of contact tracing laws and guidelines
The capacity of health care providers to carry out contact tracing is affected by a range of laws, however, the following information focuses solely on laws and regulation which specifically reference contact tracing provisions. These outlines should be read and understood in conjunction with laws on privacy and confidentiality (Privacy and Confidentiality) and policies on managing people who put others at risk of HIV infection (Management of People with HIV Who Place Others at Risk).
State based contact tracing laws and guidelines are listed below.
Contact tracing is usually carried out by the treating doctor who decides with their patient how to inform contacts. If a person refuses to tell his or her sexual contacts and refuses consent for his or her health care worker to do so, the Public Health Act (section 108) states the health care worker may inform the Chief Health Officer who may take reasonable steps to inform the contact of his or her potential exposure to HIV. The Chief Health Officer may delegate that responsibility to a doctor, nurse practitioner or suitably qualified and experienced counsellor. The Act also states (section 106) that an authorised officer can request an HIV-positive person (the index case) to provide the names and contact details of persons who may have transmitted HIV and persons to whom the index case may have transmitted the infection, and the circumstances in which transmission may have occurred. (The section states the index case cannot refuse without ‘reasonable excuse’, which is not defined). Section 106 is likely to be used only in instances when a health care provider is concerned a person may be or has put another at risk.
The framework for contact tracing is set out in section 56 of the Public Health Act 2010 and section 22 of the Health Administration Act 1982. These Acts include provisions for protection of confidentiality and for the management of situations where the index case either refuses to consent to contact tracing or is behaving in a manner which places the health of the public at risk.
In general, NSW Health’s Policy Directive 2005_184 Contact Tracing Guidelines for the Sexually Transmissible Diseases and Blood Borne Viruses provides a framework for contact tracing. Compliance with the directive is mandatory for those in the public health sector, and it may be understood as guidance for those in the private sector. The policy directive outlines different contact tracing methods and states that in most instances consent must be obtained, however, in exceptional cases where consent is consistently refused, contact tracing without consent of the index case may occur following authorisation by the Director-General of NSW Health.
Note: NSW Health Policy Directive ‘Contact Tracing Guidelines for the Sexually Transmissible Diseases and Blood Borne Viruses’ is yet to be revised to bring it in line with the recently enacted Public Health Act 2010. The policy will soon by redrafted. In the interim, references to the Public Health Act 1991 may be interpreted as relating to corresponding sections in the Public Health Act 2010.
Generally the treating doctor is responsible for undertaking contact tracing in consultation with his or her patient, although departmental contact tracers may become involved if the notifying doctor requires assistance. The Notifiable Disease Act (section 9) states that an HIV-positive person must provide his or her doctor, medical officer or authorised person with the names and addresses of all persons from whom they may have contracted HIV, and all persons to whom they may have transmitted the infection.
Generally health care provider and patient decide on the most appropriate way to make contact with previous sexual partners, which is frequently done by the patient but also by the relevant health practitioner. The matter can also be delegated to a specialist contact tracer.
The Public Health Act contains a number of provisions relating to contact tracing (including section 99) which can be enforced to require an HIV-positive person to provide the names and contact details of persons who may have transmitted HIV and persons to whom the index case may have transmitted the infection (unless the person has ‘a reasonable excuse’ [section 100] which is not defined). The Chief Executive can authorise the disclosure of confidential information for a number of reasons including contact tracing (section 80). Contact tracing officers from Queensland Health have numerous functions under section 89, including identifying persons who may have contracted or transmitted HIV and providing those persons who have contracted HIV with information to prevent or minimise the transmission of HIV. Section 108 allows disclosure of confidential information (authorised by the Chief Executive) by a relevant person to protect the health of another person, and section 109 allows disclosure (again authorised by the Chief Executive) if such is deemed to be in the public interest.
Contact tracing provisions are not specifically addressed under South Australian law unless significant concern exists, when section 75 of the South Australian Public Health Act 2011 states a person can be required to 'provide such information as may be reasonably required in the circumstances'.
Generally the notifying doctor can either initiate contact tracing and report progress to the health department’s Clinic 275 Contact Tracing Officers or refer the patient to Clinic 275 for them to perform contact tracing. In the latter case, Clinic 275 confirms patient details with the notifying doctor. Contact tracing generally occurs with the cooperation of the patient, and the patient is encouraged to engage with contact tracing services voluntarily.
Tasmania’s Guidelines for Notification of Notifiable Diseases, Human Pathogenic Organisms and Contaminants2 state that ‘contact tracing will be undertaken between the clinician and the patient, with support from Sexual Health Service Staff as required’, and includes a simple diagrammatic outline of possible contact tracing processes (p.7). Under the HIV/AIDS Preventative Measures Act Section 20, Division 3, Orders 20 (4) to (8), an HIV-positive person may ask his or her medical practitioner or approved health care worker to inform and counsel their sexual contact(s). (That request must be made in writing.) The medical practitioner or approved health care worker must comply whenever possible.
The Guidelines also state that as contact tracing is an important part of infectious disease control, the Director may therefore require additional information to be provided on actual and potential patient contacts.
The Tasmanian Act states that a medical practitioner who becomes aware following diagnosis and discussion that his or her HIV-positive patient has not taken all reasonable measures and precautions to prevent the transmission of HIV may, after consultation with an approved specialist medical practitioner, inform any sexual contact of that person of the HIV or HIV antibody status of that person, and will not be liable to any civil or criminal liability in relation to that action.
Victoria’s Partner Notification Officers document states that usually the doctor who makes an HIV diagnosis or the diagnosed patient will advise their partner(s) of the possibility of HIV infection. Sometimes, however, patients or doctors may find it difficult or may be unable to advise the partner and may request assistance, after which the matter will be referred to a Partner Notification Officer.
Contact tracing provisions are not specifically addressed under Western Australian law, however, the Guidelines for Managing Sexually Transmissible Infections state that ‘contact tracing is an important element of STI/HIV care and prevention for communities, and this must be addressed by the diagnosing clinician’. Contact tracing should be voluntarily and without coercion. When a patient refuses to notify or permit notification of contacts, assistance is available from regional Public Health Units, Aboriginal Community Controlled Health Services and the Communicable Disease Control Directorate.
1Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM). The Australasian Contact Tracing Manual. A practical handbook for health care providers managing people with HIV, viral hepatitis, other sexually transmissible infections (STIs) and HIV-related tuberculosis. Canberra: Commonwealth of Australia; 2010. Available at: ctm.ashm.org.au (last accessed November 2012.