Table I.

Summary of quantitative studies (n=16) on the criminalization of HIV exposure in the United States

Author (year)	Study objectives	Location	Study design	Sample or data	Key findings
Lazzarini et al. (2002) (9)	To identify state HIV exposure laws and prosecutions and to evaluate the impact of laws on state HIV prevalence	National	Survey of statutes and prosecutions	U.S. HIV exposure laws, cases, and news reports between 1986 and 2001	316 prosecutions in 36 states and U.S. territories were identified and outcomes of 228 cases were reported. State prevalence of HIV infection did not differ between states that had and did not have criminal HIV exposure laws
Duru et al. (2006) (48)	To examine relationships between sex without HIV-positive serostatus disclosure and sexual and substance use behaviors, relationship characteristics, and HIV exposure laws	National	Cross-sectional researcher-administered survey	PLH1 (n=875) receiving care in hospitals, clinics, and private practice settings in states with (n=534) and without (n=341) HIV exposure laws. Sample included MSM2 (n=419), women (n=299), and heterosexual men (n=157)	No association was found in the proportions of persons engaging in sex without serostatus disclosure among PLH residing in states with and without HIV exposure laws
Burris et al. (2007) (31)	To test the null hypothesis that differences in HIV-related criminal laws and participants' beliefs about their state law do not influence condom use during last anal or vaginal sexual encounter	Chicago, New York City	Cross-sectional researcher-administered survey	MSM and PWID3 (n=490) in a state with an HIV exposure law (Chicago, IL, n=248) and a state without one (New York City, NY, n=242). Sample included PLH (n=162) and persons who were HIV-negative or unknown serostatus (n=328)	Having unprotected anal or vaginal sex with one's last sex partner was not associated with beliefs about whether law requires condom use. Disclosing one's serostatus to one's last partner was not associated with state law requirements. Residing in a state with an HIV exposure law was associated with being more likely to having used a condom during last vaginal sex but not during last anal sex
Galletly and Pinkerton (2008) (46)	To evaluate the effectiveness of hypothetical “strict” and “flexible” HIV exposure laws at reducing HIV transmission risk	California	Mathematical modeling and analysis of secondary data	Men who were HIV-positive (n=206)a including MSM (n=85), MSMW4 (n=72), and 24% MSW5 (n=49)	Models of both “strict” and “flexible” HIV exposure laws would prompt behavior change. Strict laws would require seropositive disclosure to prospective partners before any sexual activity. Flexible laws were found to be more effective by criminalizing only high-risk sexual activities without disclosure, and providing PLH with two options, disclosure or low risk sex, but do less to protect partners' opportunity to determine the level of risk they were willing to take
Delavande et al. (2008) (47)	To estimate the effect of HIV-related prosecutions on PLH's sexual behaviors using an economic model of risky sexual behavior with criminal enforcement	National	Quantitative analysis of secondary data, computer modeling	HIV-related prosecution data (9) and sexual activity data of 1,421 PLHb	Simulations of estimated deterrent effects of prosecution rates on number of partners and unsafe sex suggested that a 100% increase in prosecution rates would reduce new infections by roughly 36% over a ten-year period
Francis and Mialon (2008) (34)	To apply a signaling model of sexual behavior and HIV testing to examine the efficiency of current HIV exposure criminal laws and to develop the most effective law	N/A	Mathematical modeling and analysis	N/A	The optimal law should include a penalty for knowing and unknowing HIV transmission, therefore creating an incentive for HIV testing, and should not have a penalty for exposure without transmission, thus encouraging safer sex
Wise (2008) (32)	To examine the associations between HIV exposure laws, HIV testing rates and state HIV incidence	New Jersey, California, Virginia, North Carolina, Oregon, Texas	Quantitative analysis of secondary data (time-series designs)	Monthly HIV tests including tests with reported risk behavior and HIV incidence data collected between 1997 and 2004 from publicly funded HIV testing sites in states with HIV exposure laws (New Jersey, California, Virginia) and states without such laws (North Carolina, Oregon, Texas)	In New Jersey, there were significant increases in total monthly HIV tests and confidential tests during the month laws were enacted; HIV incidence decreased at 6-month delay from enactment of the law. In Virginia, total monthly tests increased when the law was implemented. No impact on total tests was found in California. No change in testing was detected among individuals at high risk for HIV infection
Galletly et al. (2009) (39)	To assess awareness and understanding of the state's HIV exposure law and to identify sources of information about the law and participant satisfaction with these sources	Michigan	Cross-sectional self-administered survey	PLH (n=384) including men (n=133), women (n=241), transgender persons (n=3), and unknown gender (n=7)	Most participants (76%) were aware of Michigan's HIV exposure law. More than 86% of participants correctly identified circumstances when the law did and did not apply; however, many participants 1(70%) were unaware of the penalty for non-disclosure. Most participants (80%) learned about the law from multiple sources and found HIV-specific sources (e.g., support groups, flyers, AIDS Service Organizations) most helpful
Horvath et al. (2010) (33)	To assess attitudes toward the criminalization of HIV exposure through unprotected sex and whether attitudes and sexual risk behavior differed by participants' residence in states with and without HIV exposure laws	National	Cross-sectional self-administered online survey	MSM (n=1725) including PLH (n=241) and persons who were HIV-negative (n=1319) and serostatus unknown (n=149)	Almost half (48%) of MSM who were HIV-positive believed it should not be illegal for PLH to have unprotected sex without disclosure, while 70% of HIV-negative MSM, and 69% of MSM with unknown HIV status, held the opposite view. No difference was found in attitudes or sexual risk behavior of persons living in states with and without HIV exposure laws
National Alliance of State and Territorial AIDS Directors (2011) (25)	To examine awareness of state HIV criminal laws and prosecutions, and policies and procedures related to HIV exposure incidences and the release of medical records	National	National Cross-sectional self-administered survey	State and territorial HIV/AIDS program administrators (n=38)	More than half (55%) of survey respondents reported that 1) their state had an HIV exposure law and that individuals had been prosecuted for intentional exposure or non-disclosure; and 2) their state did not have policies or procedures requiring PLH to acknowledge potential criminal liability if engaged in sexual intercourse without disclosure The majority (66%) stated that their state health departments had policies related to the release of medical records to law enforcement in alleged HIV exposure cases
Galletly et al. (2012) (40)	To examine associations between awareness of the state's HIV exposure law and serostatus disclosure, risk reduction efforts, and inadvertent negative effects of the law on PLH	Michigan	Cross-sectional self-administered survey	PLH (n=384) including men (n=133), women (n=241), transgender persons (n=3), and unknown gender (n=7)	The majority of participants were in compliance with the law (i.e., reported sexual abstinence in the past year (71%) or disclosed to all sex partners prior to first sexual encounter (61%)). Awareness of the law was not associated with increased HIV-positive status disclosure to all sex partners, decreased risk behaviors, increased perceived prevention responsibility, or HIV-related stigma. Awareness of the law was associated with disclosure to a greater proportion of sexual partners prior to first sexual encounter
Galletly et al. (2012) (41)	To examine associations between PLH's awareness of New Jersey's HIV exposure law and HIV-related attitudes, beliefs, and sexual and serostatus disclosure behaviors	New Jersey	Cross-sectional self-administered survey	PLH (n=479) including men (n=256), women (n=213), transgender persons (n=7), and unknown gender (n=3)	Half of participants (51%) were aware of the law. Awareness was not associated with increased HIV status disclosure or sexual abstinence. Participants who were unaware of the law were less comfortable with HIV status disclosure and perceived greater stigma and societal hostility toward PLH
Sprague and Strub (2012) (44)	To examine PLH's awareness of and beliefs about criminal HIV exposure laws	National	Cross-sectional self-administered online survey	PLH (n=2076) including men (n=1718), women (262), transgender persons (n=20), and unknown gender (n=76)	The majority of participants (63%) were not sure whether a statute in their state required serostatus disclosure and 48% did not know which behaviors put them at risk for arrest. A quarter of participants (28%) reported that they knew individuals who did not want to be tested due to fear of prosecution
Galletly and Lazzarini (2013) (6)	To examine individual case reports of persons charged with HIV exposure and aggravated prostitution	Nashville, Tennessee	Review of case reports between January 1, 2000 and December 31, 2010	27 arrests (25 persons) for HIV exposure and 25 arrests (23 persons) for aggravated prostitution	The majority of individuals charged with HIV exposure were male (74%) and white (56%). Those charged with aggravated prostitution were mostly female (68%) and white (52%). The median sentence was 30 months for HIV exposure, and 9 months for aggravated prostitution. More than half of aggravated prostitution cases (52%) involved oral sex and 41% of exposure cases involved spitting, scratching and biting
Phillips et al. (2013) (49)	To examine the associations between individuals' perceived social capital (i.e., resources to enhance life chances and overcome challenges), HIV exposure laws and prosecutions, and HIV ART6 adherence	California, Hawaii, Illinois, Massachusetts, New Jersey, New York, North Carolina, Ohio, Texas, Washington, Puerto Rico, Canada	Cross-sectional self-administered survey (for perceived social capital and adherence data) and review of HIV criminal exposure laws and prosecutions	PLH (n=1873) including men (n=1299), women (n=503), transgender persons or other (n=51), and unknown gender (n=20)	Most participants (85%) were prescribed HIV ART. ART adherence in the past month was associated with perceived social capital, living in a state with an HIV disclosure law or HIV-specific criminal law
Lee (2014) (26)	To examine associations between HIV exposure laws, HIV testing rates among individuals at increased risk of contracting HIV living in states with and without HIV-specific statutes, and media reports on HIV exposure criminalization	National	National Quantitative analysis of secondary data	Data collected between 2002 and 2009 of U.S. HIV exposure laws, HIV testing ratesc (men (n=5242) and women (n=5836)), media reports, and AIDS Drug Assistance Programs' spending	Living in a state with an HIV exposure law was not associated with having been tested for HIV in the past 12 months. Increased media reporting of criminalization was associated with a decrease of HIV testing rates in states with HIV exposure laws

¹PLH: people living with HIV

²MSM: men who have sex with men

³PWID: persons who inject drugs

⁴MSMW: men who have sex with men and women

⁵MSW: men who have sex with women

⁶ART: antiretroviral therapy

^aMarks G, Crepaz N. HIV-positive men's sexual practices in the context of self-disclosure of HIV status. J Acquir Immune Defic Syndr. 2001;27(1):79-85

^bHIV Cost and Services Utilization Study (1994-2000). Rockville, MD: Agency for Healthcare Research and Quality

^cBehavioral Risk Factor Surveillance System (1983-2014). Atlanta, GA: Centers for Disease Control and Prevention.