Action plans needed for willful transmissions
CDC considers public health guidelines
When it came to light that LaShawn Williams had infected more than a score of his sex partners with HIV in New York's Chautauqua County, the reaction was one of shock and disbelief. But federal health officials say the willful behavior that fueled the cluster of infections was not unprecedented, and that public health departments need to develop a plan of action should a similar incident happen in their jurisdiction.
Based on anecdotal reports from health officials invited to a recent CDC conference on rural AIDS, the probability of cluster infection linked to willful infection is increasing. Or at least health officials are becoming more aware of such behavior, says David Holtgrave, MD, director of the CDC's Division of HIV Prevention - Intervention, Resource, and Support. When asked to share case studies that have challenged them, the majority of their concerns were related to cases in which people have knowingly exposed partners to the virus.
Willful exposure rare but significant
"It is interesting that some of the cases bore some resemblance to Chautauqua County," Holtgrave recently told members of the CDC's Advisory Committee for HIV and STD Prevention. "They felt they had clusters related to willful exposure and asked for tools on how to handle an outbreak."
Although willful exposures to HIV are rare, the CDC considers the problem significant enough that it is developing relevant guidelines for public health departments, such as deciding how and when to collaborate with law enforcement and the media. Willful exposures are set apart from other cases in which the risk of HIV infection is known, such as situational factors that make it difficult to disclose one's status and avoid sex without a condom or cases where there is negligence to disclose one's status due to alcohol or drug abuse, CDC officials note.
The seemingly gross willfulness of Williams and the size of the cluster in Chautauqua County propelled it into national prominence. But CDC officials say it was only unique in that the virus was so easily transmitted. Cases in which individuals knowingly expose their partners are well-documented with other infectious diseases.
"We know that a small minority of people contribute disproportionately to the epidemic of STD infection, and that has to be true for HIV, although it is not as well-studied," says Kevin DeCock, MD, director of the CDC's Division of HIV/AIDS Prevention, Surveillance, and Epidemiology. "There is nothing special about Chautauqua. It's just that HIV got into that cluster and was very efficiently transmitted."
Instead of clusters being more widespread now, it may just be that the social networks leading to cluster infections are easier to observe because relationships are easier to track in rural areas, experts say.
"You are able to look at these microphenomena, whereas in urban areas where you have more hyper-endemic levels you can't dissect them out," said King Holmes, MD, PhD, director of the Center for AIDS and STDs at the University of Washington in Seattle.
Preparing for the next Chautauqua County
What was unique about Chautauqua County was the level of publicity and degree of involvement with agencies outside public health. And while the collaboration drew more praise than criticism, the lesson learned was that there was no plan of action, says Lawrence Gostin, JD, a professor of law at Georgetown University who was involved in the case.
"There was a lot of goodwill and cooperation, but the one fact that was inescapable was that it had not been preplanned," he said. "There hadn't been any forethought for the kinds of principles and practices that are needed."
Health officials agree that a plan of action is needed, considering that more cases are likely to happen.
"As the number of people infected with HIV grows, the probability increases that you will get a sexual predator who uses this particular way of acting out," says Robert Fullilove, EdD, associate dean for community and minority affairs at Columbia University in New York City. "So we should just accept the fact that we are going to be seeing this more and more. It's going to happen, and we need to help people prepare for it."
Gostin outlines the options available to health departments and the impact their actions could have on their image in the community. The first question that must be answered is: What type of situation acts as a trigger for putting a plan into action? Could it be one or two infections, or does it have to be as extensive as it was in Chautauqua County?
Once that trigger is pulled, a county is faced with several decisions. The first is whether there is a need for law enforcement involvement. That was the decision made by health officials in Chautauqua County, but it can have detrimental consequences, Gostin warns.
"Once it gets out in the community that you are going to be referring certain cases to law enforcement, what does that do to your counseling and testing program?" he asks. "It might be telling the community that it is better not to know your status or better not to tell your status."
In many states, says Gostin, public health officials have inherent police-type powers that can range from cease-and-desist orders to orders that patients be placed in isolation. New York health officials have considerable public health powers, which made it surprising that they decided to seek the assistance of law enforcement, he adds.
Another decision is whether to go public with the case, which was the tactic taken by Chautauqua County health officials. Public disclosure of Williams' name was one of the most controversial aspects of the case, and posed legal and ethical questions over whether he was treated differently because he had HIV. When health officials were asked why they went public, Gostin says, they responded by saying it was a form of partner notification - Williams had so many sex partners that officials couldn't find them all without the public's help.
States responding
Julie Schofield, a representative from the National Association of State and Territorial AIDS Directors, told the advisory committee that the issue of willful exposure has generated increased interest among health officials, particularly as states have developed laws to address it. In Missouri, for example, HIV-positive people are categorized into three categories related to the perceived risk of transmitting the virus to partners, she said. State health officials estimate that about .3% of people infected in the state fall into the highest-risk category and are given ongoing counseling and support, she added.
In June, Alaska Gov. Tony Knowles vetoed legislation making willful spread of HIV a felony. Passed in May by the state legislature, the bill would have made it a crime to sell tainted blood or for people who are infected with HIV and who are aware of their serostatus to have sex with someone who is unaware of the HIV-positive person's infected status. The governor vetoed the bill, which would have been the first time a disease in the state was criminalized, because the state already has protective laws against reckless endangerment and several forms of assault.
Willful exposures were most prevalent in correctional facilities in the early years of the epidemic, often in the form of prisoners using their infections as a way of intimidating guards through blood exposures, says Nadim Khoury, MD, assistant deputy director for health care services for the California Department of Corrections. Cases declined as more prison officials became versed in the risks of exposure and universal precautions, he added.
Once the CDC develops guidelines, it may include them with the upcoming partner counseling and referral services guidelines or publish them as a separate document.
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