Table III.
Summary of key findings by topic of empirical studies on criminal HIV exposure laws
| Topic | Author (year) | Key findings |
|---|---|---|
| Awareness and understanding of the laws | Klitzman et al. (2004) (28) | HIV-positive interview respondents (n=76) were unable to distinguish terms related to criminalization such as “non-disclosure”, “unsafe sex” or “intended infection” |
| Galletly and Dickson-Gomez (2009) (38) | HIV-positive focus group participants (n=31) did not understand the distinction between criminal prosecutions and civil actions with a monetary award in the case where a person was accused of violating the state's disclosure law | |
| Galletly et al. (2009, 2012) (39, 40) | A majority (76%) of the HIV-positive participants (n=384) were aware that their state had an HIV exposure law. Most who were aware of the state law recognized its basic requirements (e.g., 85% were aware that seropositive status disclosure was required prior to even protected anal or vaginal intercourse) (27) | |
| Kelly et al. (2011) (30) | A majority of female HIV-positive survey respondents (n=103) were aware that the U.S. had HIV exposure laws but were unsure if their state had such a law or what the law required | |
| Close (2012) (27) | Physicians (n=3) were not aware of details of North Carolina's HIV control measures. Some physicians and health department employees were unsure if their clients who were HIV-positive understood the details of the control measures and how they were enforced | |
| Galletly et al. (2012) (41) | Fifty-one percent (n=244) of HIV-positive survey participants in New Jersey were aware that their state had an HIV exposure law | |
| Sprague and Straub (2012) (44) | Nearly two-thirds of HIV-positive participants (63%, n=1297) were unsure about whether there was an HIV-specific law in their state that required serostatus disclosure. Nearly half of respondents (48%, n=593) were unsure what behaviors were prohibited | |
| Attitudes toward the laws | ||
| Support for the laws | Klitzman et al. (2004) (28) | Of 76 PLH1 who were interviewed, most believed that HIV exposure laws could reduce HIV transmission by increasing disclosure. Some supported the laws only under specific circumstances such as in the case of rape or when a PLH lied about his or her status |
| Galletly and Dickson-Gomez (2009) (38) | Focus group participants who were HIV-positive (n=31) endorsed the presumed goal of Michigan's HIV disclosure law, which was to prevent infection of uninfected sex partners | |
| Horvath et al. (2010) (33) | Sixty-five percent of a sample of 1725 HIV-positive and -negative MSM2 believed that it should be illegal for a PLH to have unprotected sex without seropositive disclosure; however, only 38% of HIV-positive participants shared this belief. MSM who were HIV-positive (OR=0.33; 95% CI=0.24-0.44; p ≤ .000), lived in states perceived as somewhat or very accepting toward homosexuality (OR=0.75; 95% CI=0.59-0.96; p = .023), held a baccalaureate (OR=0.53; 95% CI=0.35-0.78; p = .002) or graduate degree (OR=0.42; 95% CI=0.27-0.64; p = .000), and had two or more unprotected anal sex partners in the past three months (OR=0.72; 95% CI=0.56-0.93, p = .013) were less likely to support the criminalization of HIV exposure | |
| Close (2012) (27) | Most health department employees and HIV care providers who were interviewed (n=11) identified compulsory partner notification services as the most useful component of the state's HIV control measure given that the program prompted more PLH to notify their partners and link them into testing and care | |
| Galletly et al. (2012) (40) | Over two-thirds (71%, n=384) of HIV-positive survey participants were in compliance with Michigan's HIV exposure law (e.g., reported sexual abstinence in the past 12 months, disclosed positive serostatus to all vaginal, anal, and oral sex partners prior to first sex). Most participants supported criminalization of unprotected sex without disclosure (88%), lying about HIV status to have sex (91%) and intentional exposure to infect (97%) | |
| Galletly et al. (2012) (41) | Among 479 HIV-positive survey participants in New Jersey, 54% believed that it should be against the law for a PLH to engage in condom-protected sex without disclosure and 87% believed that it should be a crime for a PLH to have unprotected sex with an uninformed partner. In multivariate analysis, predictors of compliance with the law were support for criminalization (OR=1.53; 95% CI=1.24-1.88) and comfort with disclosure (OR=0.50, 95% CI=0.30-0.83) | |
| Lichtenstein et al. (2014) (43) | In North Carolina where the state's disease control measure was more restrictive and had more severe penalties than Alabama's HIV exposure law (e.g., liable to up to 2 years' in NC and 3 months' imprisonment in AL), most HIV care providers who were interviewed in North Carolina (90%, n=18) supported the use of HIV exposure laws compared to 45% (n=9) of providers in Alabama | |
| Concerns about and opposition to the laws | Galletly and Dickson-Gomez (2009) (38) | HIV-positive focus group participants (n=31) were concerned about unwanted secondary disclosure and/or being falsely accused of non-disclosure. Many believed that it was unfair to assign the entire burden of HIV prevention to PLH. Participants also expressed concern about discrimination against PLH in the criminal justice system |
| Kelly et al. (2011) (30) | In open-ended survey questions, female HIV-positive participants (46%, n=47) believed that criminalization could be harmful for women living with HIV. Concerns included that criminalization could increase HIV-related stigma, reinforce discrimination against PLH, and be used as a tool of abuse by partners by falsely accusing PLH of not disclosing. Over half (56%, n=58) believed that the laws could deter persons at risk from being tested and undermine adherence efforts among PLH | |
| Klitzman et al. (2004) (28) | HIV-positive participants who were interviewed (n=76) believed that the criminalization of HIV exposure could deter testing and be used to falsely accuse PLH of intentional exposure or transmission. Safer sex was perceived as a better prevention strategy than disclosure. Participants also believed that serostatus disclosure should be an individual responsibility, not a legal requirement | |
| Close (2012) (27) | Care providers and health department employees who were interviewed (n=11) believed that their state's HIV control measure would not deter PLH from engaging in sexual risk behaviors because the law was rarely enforced and because individuals engaged in these behaviors in private. Participants also believed that criminalization could discourage PLH from participating in partner notification services | |
| Sprague and Strub (2012) (44) | Over one-third of online HIV-positive survey respondents (38%, n=765) stated that they had ever worried about being falsely accused of not disclosing their status. Nearly half of respondents (49%) thought that they would not be given a fair hearing in their state criminal justice system if they were accused of non-disclosure | |
| Lichtenstein et al. (2014) (43) | Twenty-five percent (n=5) of HIV care providers living in a state with less strict penalties for non-disclosure opposed the laws. Concerns cited included that the laws could increase stigma, deter persons at risk from testing, impede engagement in HIV care, and act as a communication barrier between providers and PLH | |
| Perceived responsibility for HIV transmission prevention and HIV exposure laws | Horvath et al. (2010) (33) | MSM (n=1725) who had lower perceived responsibility to protect their sexual partners from HIV or STIs3 were less likely to believe that it should be illegal for a PLH to have unprotected anal sex without HIV status disclosure (OR=0.75; 95% CI=0.69-0.81; p = .000) |
| Kelly et al. (2011) (30) | Among female HIV-positive participants (n=103), those who thought that HIV exposure laws were not harmful to PLH (27%) were more likely to believe that PLH held the sole responsibility for preventing new infections (OR not reported) | |
| Galletly et al. (2012) (41) | There was no difference in perceived responsibility for HIV transmission prevention between PLH (n=479) who were aware (51%) and unaware (49%) of their state HIV exposure law. Most participants (90%) believed that PLH were responsible for preventing forward | |
| Criminalization of HIV exposure and seropositive status disclosure | ||
| Increased disclosure | Gorbach et al. (2004) (42) | Among interviewed HIV-positive MSM (n=55) reporting recent unprotected sex or an STI, fear of arrest and knowing that seropositive status disclosure was required by law were cited as reasons to disclose |
| Decreased disclosure | Delavande et al. (2008) (47) | HIV-positive persons living in states with greater than median prosecution rates for knowing exposure to HIV were significantly less likely to disclose to partners (p ≤ .01) |
| No effect on disclosure | Duru et al. (2006) (48) | No difference 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) | Seropositive status disclosure to sex partners did not differ between persons living in states with and without HIV exposure laws | |
| Galletly et al. (2012) (40) | HIV-positive participants who were aware of their state's HIV exposure law were no more likely to have disclosed to all of their sex partners in the previous year than those who were not aware of the law; however, sexually active participants who were aware of the law did report disclosing to sex partners prior to having sex with them for the first time more often than sexually active participants who were not aware (p = 0.04) | |
| Galletly et al. (2012) (41) | Awareness of the law was not associated with having disclosed HIV status to a greater proportion of partners | |
| Lichtenstein et al. (2014) (43) | Citing clients being evasive or agreeable during counseling sessions about HIV and the laws, all but one HIV care provider who were interviewed (n=39) believed that mandatory serostatus | |
| Criminalization of HIV exposure and sexual behaviors of HIV-positive persons | ||
| Sexual abstinence | Delavande et al. (2008) (47) | HIV-positive persons living in states with greater than median prosecution rates for knowing exposure to HIV were more likely to report having been sexually abstinent than those living in states with median or below prosecution rates (p ≤ .05) |
| Galletly et al. (2012) (41) | HIV-positive participants who were aware of their state's HIV exposure law were not more likely to have been sexually abstinent for the previous year than those who were unaware of the law | |
| Number of sex partners | ||
| Decreased | Delavande et al. (2008) (47) | HIV-positive persons living in states with greater than median prosecution rates for knowing exposure to HIV reported having fewer sex partners than those in states with lower prosecution rates (p ≤ .1) |
| No difference | Galletly et al. (2012) (40, 41) | There was no significant difference in the number of reported sex partners in the past year among HIV-positive participants who were and were not aware of their state's HIV exposure law |
| Frequency of sex with and without condoms | ||
| Decreased sex without condoms | Delavande et al. (2008) (47) | HIV-positive persons living in states with greater than median prosecution rates for knowing exposure to HIV reported engaging in unprotected sex less often than those in states with lower prosecution rates (p ≤ .05) |
| No difference in sex without condoms | Horvath et al. (2010) (33) | HIV-positive persons living in states with and without HIV exposure laws reported similar numbers of casual, unprotected anal sex partners in the last three months |
| Burris et al. (2007) (31) | There was no difference in condom use during last anal or vaginal sex between HIV-positive participants who believed and did not believe that state law required them to use condoms | |
| Increased condom-protected sex | Burris et al. (2007) (31) | HIV-negative and HIV-positive participants living in a state with an HIV exposure law were more likely to have engaged in protected vaginal sex with their last sexual partners (OR=5.40; p ≤ .001) |
| Increased sex without condoms after seropositive status disclosure | Burris et al. (2007) (31) | HIV-positive participants living in a state with an HIV exposure law were more likely to have engaged in unprotected anal sex after disclosing their positive serostatus to sexual partners than those living in a state without an HIV-specific law (OR=0.06; p ≤ .001) |
| Increased sex with prostitutes | Delavande et al. (2008) (47) | Living in states with greater than median prosecution rates for knowing exposure to HIV was associated with an increase in the probability of sex with a sex worker among PLH who had more than one sex partner (p ≤ .05) |
| Criminalization of HIV exposure and HIV-related risk behaviors of persons who are HIV-negative or status unknown | ||
| Increased testing rates | Wise (2008) (32) | An increase in testing rates was found on the month of the enactment of the laws in two study states with criminal laws (i.e., New Jersey (t = 2.360; p = .20) and Virginia (t = 3.588, p = .001), but not in California). Testing rates among persons at risk for HIV infection did not increase |
| Decreased testing rates | Lee (2014) (26) | Increased media reporting on criminalization of HIV exposure was associated with a 7% to 9% decrease of HIV testing rates in states with HIV-specific laws (p = .01). There was no difference in reporting having been tested for HIV in the past 12 months between persons at risk for HIV infection living in a state with an HIV exposure law and those living in a state without an HIV-specific law |
| Increased risk behaviors | Burris et al. (2007) (31) | There was no difference in reporting having engaged in sex without a condom during last sexual encounter between HIV-negative participants who believed that the law required PLH to disclose or to use condoms and those who did not share this belief. A greater proportion of HIV-negative residents of a state with an HIV-specific exposure law reported engaging in unprotected vaginal sex than the state residents who were HIV-positive (OR=.035; p = .012) |
| No difference in HIV-related risk behaviors | Delavande et al. (2008) (47) | There were no differences in reported number of partners, having engaged in sex without a condom or having paid for sex between HIV-negative individuals living in states with greater than median prosecution rates for knowing exposure to HIV and those who lived in other states. Living in states with greater than median prosecution rates was associated with a reduction in the probability of having paid for sex among HIV-negative individuals (p ≤ .1). |
| Criminalization of HIV exposure and HIV antiretroviral adherence | ||
| Greater HIV ART4 adherence | Phillips et al. (2013) (49) | HIV-positive survey participants who lived in states with laws requiring HIV disclosure reported better average 30-day HIV ART adherence (r = .065, p = .01). However, PLWH who lived in states with HIV-specific criminal laws reported lower 30-day adherence (r = −.052, p = .04). In multivariate analysis, PLH who lived in states with HIV disclosure laws were more likely to be adherent to HIV ART (OR=1.38; 95% CI=0.99-1.91, p = .054) |
1
PLH, people living with HIV
2
MSM, men who have sex with men
3
STIs, sexually transmitted infections
4
ART, antiretroviral therapy