Not the Sex Police!

They’ve been called ‘the sex police’ but meeting these three compassionate and understanding nurses, it’s hard to understand why.

Beth Hatch, Tom Carter and Andrea Edwards are contact tracers (Partner Notification Officers, to be exact) with the Victorian health department, the Department of Human Services. They are part of a public health approach that seeks to prevent the further transmission of infectious diseases (particularly HIV and STIs [1][Sexually Transmissible (or Transmitted) Infection] Infections spread by the transfer of organisms from person to person during sexual contact. Also called venereal disease (VD) (an older public health term) or sexually transmitted diseases (STDs). ) that is replicated in other states and territories around the country.

The contact tracers have the sensitive job of contacting the partners (sexual or injecting) of people who have been diagnosed with HIV or an infectious disease. Often the names of these partners will have been given to them by the person’s GP who doesn’t have the time or resources to follow up on the information the patient has provided.

When a person is newly diagnosed with HIV, for instance, the contact tracers will ring the person’s GP to see if names of partners have been given so they can do a follow-up. Sometimes social workers, psychologists or doctors may refer a person whom they believe may be putting others at risk for HIV infection, or a person who is newly diagnosed may self-refer to them.

The sensitivity of their work and the possibility that some people might be implicated in behaviour that is illegal — positive people can be charged under a range of laws around the country if they are found to be responsible for transmitting HIV — led one gay community figure to describe the Victorian tracers as “sex police” a number of years ago.

‘Softly, Softly’

“We think that is very unfair, we understand the HIV and gay communities very well, says Beth. “We take a very ‘softly, softly’ approach which could hardly be described as police-like — we listen to the stories of positive people and give them a chance to talk through this difficult area. We know all about the pressures on them to have unsafe sex,” she says.

“The other day I was talking to a guy from a country town who said that as soon as you ask someone there to use a condom, they assume you’re positive and it’s around the town in a flash.”

Contact tracers also see the newly diagnosed and hear stories of regret and anguish when people find out they’re positive. “It can be heartbreaking,” Beth admits, but “it confirms to us the importance of what we’re doing — trying to stop transmissions.”

Beth says the contact tracers are concerned at recent rises in HIV rates in Victoria. “Certainly people are not seeing as many sick people when they go out socially now because of the effects of treatments. There is also the easy availability of casual sex on the Internet. We have talked to a number of guys who are new to the gay scene and inexperienced in sexual negotiation who have become infected after meeting someone through a chat line,” she says.

“The majority of people don’t want to transmit HIV,” Beth says. “Some need help with their safe sex negotiation skills, some need to be referred for counselling, others need to be informed that their behaviour is against the law. And usually that’s the only intervention required.”

‘Knowing and Reckless’

“There are those though who are knowing and reckless in their transmission of HIV. It is not a huge number of people — at any one time, we have a handful of cases that we continue to follow up,” says Andrea.

These can include people with serious mental health problems, intellectual disabilities, drug and alcohol problems, individuals who are unaware of their sexual responsibilities or a combination of any of these. “Some can be very difficult, with little or no regard for others. With most people we’re able to build up a reasonable rapport over the period, sometimes many years, that we and other community support people work with them. They don’t think of us as terrible ogres.”

“There is the potential for some ugly scenes in our contact tracing work,” says Beth, “[but] most people are thankful that we’ve informed them that they have had contact with someone with an infectious disease. With HIV, often they say our visit has been a wake-up call, particularly if they’re still HIV-negative at the end of the process. However some become angry when they’re told they’ve been exposed without warning and they want to take revenge on their partners. We try to calm them down and say that would not be in their best interests. We will never reveal the source of the infection. We also let them know that often they are wrong about who they presume is the source of the infection, anyway.”

One of the measures that some people want to take after hearing they have been exposed to HIV (sometimes if they’ve been infected, sometimes not) is to take the person to court. This may not involve contact tracing at all. In Victoria, this involves going to the police and asking that they charge the person under the Crimes Act (there are similar laws in other states).

“There is the potential for some ugly scenes”

Depending on the part of the legislation which the prosecutor chooses to apply, an accused person in Victoria can be charged with “conduct endangering life” — placing someone in danger of serious injury — with a maximum penalty of five years in prison; or “intentionally causing a very serious disease” — meaning HIV under a 1988 amendment — with a maximum penalty of 25 years’ jail. In Victoria, three people have been successfully prosecuted under the “conduct endangering life” provision over the past years — leading to a jail term for one.

The contact tracers and indeed the majority of the HIV community in Victoria probably prefer the use of the Health Act 1958 for these types of cases (again, there are similar public health approaches in most other states). This involves the use of guidelines for the management of HIV infected people who knowingly or recklessly risk infecting others with HIV.

A five-stage approach is followed which begins with counselling and support. This involves the contact tracers and counsellors. If it fails, there is a request for a panel to be convened including several Department of Human Services appointees (usually at least one experienced counsellor and one infectious diseases physician) and a person with HIV. If their recommendations do not work and behaviour change doesn’t happen, the person can be isolated on a public health order.

Pressure to Disclose — SA perspective

Tess Davey, a contact tracer with the Department of Human Services in South Australia, understands the pressures on positive people to disclose their status and agrees with the South Australian and Victorian laws that don’t specifically require it. (In NSW, positive people are supposed to tell a sex partner they are positive before they have sex.)

“I understand the sex culture at a sauna where it is hard to disclose those sort of details, but if you’re positive and don’t disclose, you have to use a condom,” says Tess. “I know positive guys say they are sick of looking after the other person but who wants to give someone HIV?”

“I don’t take a punitive approach. I try to develop their confidence to discuss the issues, sometimes over several months, and support them. If I see a positive person coming to the clinics and being referred with consistent cases of anal gonorrhoea though, there’s going to be tears at the end of the day. They have to change their behaviour.”

NSW — Different Approach

In NSW the approach to contact tracing seems to be quite different. Dr Chris Bourne, an HIV specialist with the Sydney Sexual Health Centre, told me that under the NSW Public Health Act 1991, responsibility for contact tracing is the particular responsibility of the person’s GP. They are supposed to ask someone diagnosed with an infectious disease to contact their partners and where possible the practice will help these people to get treatment where necessary.

GPs are involved in this process in other states too but clearly it is labour-intensive and a doctor cannot be expected to spend much time doing this work — which is why contact tracers are used. Chris told me that Area Health Service Sexual Health Officers will assist GPs with contact tracing work in NSW unlike the centralised system used in other states.

“It is difficult to do contact tracing in the gay community though, when so many people are having sex with anonymous partners. We have limited success getting people to contact their sexual partners unless they have swapped phone numbers or information like that,” he says.

“When HIV came along in the 1980s we had to learn to do things differently in public health, ” says Chris. “To achieve results in reducing transmissions we had to develop the trust of the community by not taking a punitive approach. Without this, people wouldn’t come in to be tested; they would be concerned that we would breach their confidentiality. So when it comes to limiting the spread of HIV, we rely on education campaigns through organisations like ACON. We have developed campaigns to encourage testing and treatment in the past. At the moment we are trying to develop a culture amongst gay men where they will go to their doctor for regular check-ups for STIs.”

“Of course there are people who are knowingly infecting others with HIV. We think that a person’s primary health care provider is most likely to know most about a person’s sexual practices and to pick up if they are being irresponsible with unsafe sex. If this happens they can refer the person to the Health Department. As with other states, we have a public health process to deal with these people which can lead to measures being taken to restrict the person’s behaviour.”

I’m sure Chris Bourne is right when he says that contact tracing amongst the gay community is difficult due to the high numbers of casual, anonymous encounters. It is a moot point as to whether the seemingly more conscientious approach to the issue by Victoria and South Australia is making a huge difference or not — maybe the number of successful contacts is only the tip of the iceberg. It does seem that the work of contact tracers is important where contacts can be identified, as it must help to reduce the number of further infections — and it is essential when it comes to working with the small number of people who are behaving irresponsibly.