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Examining public health nurses’ documentary practices: the impact of criminalizing HIV non-disclosure on inscription styles

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Abstract

In Canada, there has been a rise in criminal HIV non-disclosure cases where public health records have been subpoenaed for use in police investigations and criminal court proceedings. In particular, public health nurses’ written counseling notes, originally collected for the purposes of creating a record of treatment and a plan of care, have been used as evidence against their clients. This article engages sociologically with this issue by analyzing whether and how this criminal law development has affected public health nurses’ reasoning and documentary practices in settings of HIV post-test counseling sessions. The paper argues that variations in nurses’ inscription styles result in part from considerations about the criminal law, which indicates the influence of ‘medico-legal’ relations that connect health care and the criminal justice system. Implications for nursing practice and the broader goals of HIV prevention are discussed. Data are drawn from interviews with thirty nurses working at four public health units in Ontario.

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... In particular, PHNs described the important task of establishing and maintaining counseling rapport as noticeably more challenging following discussion of criminalization (Sanders, 2013). They felt this undermined their ability to successfully discuss riskreduction strategies and obtain contact information for sex contacts (Sanders, 2015). PHNs also described organizational concerns about civil lawsuits against public health units in cases where patients were prosecuted for nondisclosure. ...
... They expressed concerns about being summonsed to testify against patients in court in nondisclosure cases (Sanders, 2014). These concerns led many PHNs to avoid discussing the limitations of confidentiality during counseling sessions while documenting information in patient case files that might be seen as superfluous to the plan of care but relevant to a court case in the event of an arrest for nondisclosure (Sanders, 2014(Sanders, , 2015. In short, the PHNs' reasoning and practices had become infiltrated by various extra-local concerns and personal experiences brought about by the criminalization of HIV nondisclosure. ...
... Asking ourselves if our work met these criteria, both individually and collectively as a meta-analysis, we answered all questions in the affirmative, and then spoke to each criteria either in the methodology or discussion sections of this article. With respect to the issue of qualitative transferability, we similarly feel that the organizers that we have identified in this discussion do not supplant nor reiterate the detailed finding of our previous studies (see, for example, Bisaillon, 2012bBisaillon, , 2014Bisaillon & Ells, 2014;Sanders, 2014Sanders, , 2015 but rather add to and expand the scope of our earlier analyses. ...
Article
Health sociologists interested in how macro state influences affect micro health care practices have much to gain from meta-ethnography research. In this article, we bring together insights from two separate empirical studies on state health care services involving HIV/AIDS as a way to speak to larger issues about the organization and production of medical expertise and governance in health care systems. We use Noblit and Hare’s meta-ethnography approach to bring these studies into conversation and identify six shared “organizers” of health care encounters. The organizers illustrate how state health interests operate across institutional contexts and impact the work of providers in seemingly unrelated health care settings. On the basis of this synthesis, we conclude that state interests both structure and create conflict in health care settings. We believe this perspective offers the potential to advance the goals of health sociology and the field of qualitative health research in general.
... Similarly, interviews with 30 public health nurses in Ontario revealed that the risk of subpoena of medical documentation for use in judicial trials influenced patient-provider discussions around the limits of confidentiality in the healthcare setting, with some providers withholding/limiting details about confidentiality to preserve therapeutic relationships [121]. Qualitative data drawn from the latter two studies also suggest that anticipation of possible subpoena of medical documents for use in trials may influence documentary practices within medical records, either to ensure adequate recall of clinical events, to signify professional standards are being upheld, or to maximize patient confidentiality [118,121,122]. ...
... Impact of criminal law on: Linkage and retention in HIV care Judging mothers: criminalization's creep into the health and social care of HIV-positive mothers (2014) [126]. Interviews conducted in Ontario with women in their 3rd trimester, and at 3 and 12 months postpartum.Discussing the Limits of Confidentiality:The Impact of Criminalizing HIV Nondisclosure on Public Health Nurses'Counselling Practices (2014)[122].Examining public health nurses' documentary practices: the impact of criminalizing HIV nondisclosure on inscription styles (2015)[123]. ...
Article
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Introduction: In 2012, the Supreme Court of Canada ruled that people living with HIV (PLWH) must disclose their HIV status to sexual partners prior to sexual activity that poses a "realistic possibility" of HIV transmission for consent to sex to be valid. The Supreme Court deemed that the duty to disclose could be averted if a person living with HIV both uses a condom and has a low plasma HIV-1 RNA viral load during vaginal sex. This is one of the strictest legal standards criminalizing HIV non-disclosure worldwide and has resulted in a high rate of prosecutions of PLWH in Canada. Public health advocates argue that the overly broad use of the criminal law against PLWH undermines efforts to engage individuals in healthcare and complicates gendered barriers to linkage and retention in care experienced by women living with HIV (WLWH). Methods: We conducted a comprehensive review of peer-reviewed and non-peer-reviewed evidence published between 1998 and 2015 evaluating the impact of the criminalization of HIV non-disclosure on healthcare engagement of WLWH in Canada across key stages of the cascade of HIV care, specifically: HIV testing and diagnosis, linkage and retention in care, and adherence to antiretroviral therapy. Where available, evidence pertaining specifically to women was examined. Where these data were lacking, evidence relating to all PLWH in Canada or other international jurisdictions were included. Results and discussion: Evidence suggests that criminalization of HIV non-disclosure may create barriers to engagement and retention within the cascade of HIV care for PLWH in Canada, discouraging access to HIV testing for some people due to fears of legal implications following a positive diagnosis, and compromising linkage and retention in healthcare through concerns of exposure of confidential medical information. There is a lack of published empirical evidence focused specifically on women, which is a concern given the growing population of WLWH in Canada, among whom marginalized and vulnerable women are overrepresented. Conclusions: The threat of HIV non-disclosure prosecution combined with a heightened perception of surveillance may alter the environment within which women engage with healthcare services. Fully exploring the extent to which HIV criminalization represents a barrier to the healthcare engagement of WLWH is a public health priority.
... Following the articulation by Mykhalovskiy and colleagues, a growing number of social-scientific studies in recent years have taken a broader view of healthwork in three key domains. The first is in the context of public health practices where family healthwork (Nichols et al. 2016), mental healthwork (Abraham et al. 2017), sexual healthwork (Fryer 2014), health seeking information (Harris et al. 2010;Lakoff 2015;Sanders 2015) and stroke prevention (Flogen 2014) constitute significant knowledge required by patients to take responsibility for their own health and well-being. The second revolves around healthcare services where patients make decisions about their healthcare and treatment choices based on the health information, especially in areas such as diabetes care (Arduser 2017; Lowndes 2012), breast cancer care (Goldenberg 2010;Sinding et al. 2010), women's prenatal care (Ion et al. 2020), women's preterm labor experiences (MacKinnon 2006), and patient-empowerment and health-related services (Bisaillon 2014;Veinot 2010). ...
... The questions asked by Kristen are further complicated by the increasing climate of HIV criminalisation in Canada (CATIE n.d.). While Canadian law outlines specific conditions under which people living with HIV are obligated to disclose their HIV status before sexual encounters, a climate of surveillance has crept into public health and social service arenas blurring the lines and creating confusion regarding what disclosures are needed, by whom and in what circumstances (Greene et al. , 2017Sanders 2014Sanders , 2015. In a healthcare context, even if women living with HIV do not wish their HIV status to become known, and/or healthcare providers wish to avoid unwanted disclosure of a woman's HIV status, the legal obligation of people living with HIV to disclose to sexual partners, along with parental right to know about and consent to healthcare their child receives, creates conditions where the disclosure of HIV may occur. ...
Article
This paper describes findings from an institutional ethnography that arose out of the concerns of women living with HIV in Ontario, Canada, regarding the disclosure of their HIV status while accessing perinatal care. The enquiry traces the connections between women’s experiences of perinatal care, the activities of healthcare providers delivering such care and the ruling relations that organise women’s experiences and healthcare providers’ activities. Focusing on HIV disclosure as a concern expressed by women, the findings make visible the day-to-day, routinised practices of healthcare providers working in perinatal care for women living with HIV, as well as the ideological discourses of ‘fear of contagion’ and ‘AIDS hysteria’ that contributed to producing the kinds of care experiences that were articulated by women. Opportunities to strengthen perinatal care policies and practices for women living with HIV are discussed.
... They suggest how HIV criminalization can undermine effective HIV prevention by creating a public expectation for people with HIV to disclose to their sexual partners while, at the same time, making disclosure, at least for some people with HIV, a more risky and difficult thing to accomplish. Three articles by Sanders (2015); Dodds, Weait, Bourne, and Egede (2015); and French (2015) contribute to an emerging direction in the literature that explores the public health implications of HIV criminalization through a focus on public health, health care, and social service providers. Moving past the 'person with HIV/criminal law' dyad (Mykhalovskiy, 2011), these articles produce a more relational understanding of the public health implications of HIV prevention. ...
Article
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While public health remains the primary site of authority for preventing HIV transmission, recent shifts in the biopolitics of HIV have heightened tensions in the institutional and discursive relations through which the sexual lives of people living with HIV and broader HIV epidemics are regulated. Most notably, over the past decade, criminal justice responses to HIV have gained considerable traction. The growing use of the criminal law to regulate perceived HIV transmission risks has occasioned considerable controversy among people living with HIV, community-based AIDS organizations, health-care providers, public health authorities, prosecutors, judges, and the legal community. This article introduces a special section of Critical Public Health focused on the public health implications of HIV criminalization. The article reviews past and current work on the topic, situates the contributions made by the articles published in the special section, and outlines directions for future inquiry.
... The differences between our work and that undertaken earlier could be in part because key elements of criminal liability differ significantly between the UK and Canada. 5 Yet, in more recent research among HIV specialist nurses in Canada, Sanders (2015) reveals that changes to documentation practices in the light of criminalisation include a mixture of those who document more, and those who document less as a direct result of potential use of professionals' notes in criminal proceedings, similar to our findings. ...
Article
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We present qualitative research findings about how perceptions of criminal prosecutions for the transmission of HIV interact with the provision of high-quality HIV health and social care in England and Wales. Seven focus groups were undertaken with a total of 75 diverse professionals working in clinical and community-based services for people with HIV. Participants’ understanding of the law in this area was varied, with many knowing the basic requirements for a prosecution, yet lacking confidence in the best way to communicate key details with those using their service. Prosecutions for HIV transmission have influenced, and in some instances, disrupted the provision of HIV services, creating ambivalence and concern among many providers about their new role as providers of legal information. The way that participants approached the topic with service users was influenced by their personal views on individual and shared responsibility for health, their concerns about professional liability and their degree of trust in non-coercive health promotion approaches to managing public health. These findings reveal an underlying ambivalence among many providers about how they regard the interface between criminal law, coercion and public health. It is also apparent that in most HIV service environments, meaningful exploration of practical ethical issues is relatively rare. The data presented here will additionally be of use to managers and providers of HIV services in order that they can provide consistent and confident support and advice to people with HIV.
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We present qualitative research findings about how perceptions of criminal prosecutions for the transmission of HIV interact with the provision of high-quality HIV health and social care in England and Wales. Seven focus groups were undertaken with a total of 75 diverse professionals working in clinical and community-based services for people with HIV. Participants’ understanding of the law in this area was varied, with many knowing the basic requirements for a prosecution, yet lacking confidence in the best way to communicate key details with those using their service. Prosecutions for HIV transmission have influenced, and in some instances, disrupted the provision of HIV services, creating ambivalence and concern among many providers about their new role as providers of legal information. The way that participants approached the topic with service users was influenced by their personal views on individual and shared responsibility for health, their concerns about professional liability and their degree of trust in non-coercive health promotion approaches to managing public health. These findings reveal an underlying ambivalence among many providers about how they regard the interface between criminal law, coercion and public health. It is also apparent that in most HIV service environments, meaningful exploration of practical ethical issues is relatively rare. The data presented here will additionally be of use to managers and providers of HIV services in order that they can provide consistent and confident support and advice to people with HIV.
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This report contributes to the development of an evidence-informed approach to using the criminal law to address the risk of the sexual transmission of HIV in the province of Ontario, Canada. In recent years, the application of criminal law powers to circumstances of HIV exposure in sexual relations has emerged as a key HIV-related policy issue. In Ontario, people living with HIV/AIDS (PHAs), AIDS Service Organizations (ASOs), human rights advocates and others have raised concerns about the expansive use of the criminal law in addressing HIV-related sexual offences. They have raised questions about fairness in the application of the criminal law and about its negative consequences for PHAs and established public health and community-based HIV prevention strategies. This report is rooted in these concerns. It responds to them in two ways. First, it explores various forms of evidence relevant to a thorough policy consideration of the use of the criminal law in circumstances of sexual exposure to HIV. Second, it proposes policy options for addressing the problems posed by the criminalization of HIV non-disclosure in Ontario.This report emphasizes that uncertainty in the criminal law formulation of the obligation to disclose HIV-positive status is foundational to current problems in the use of the criminal law to regulate the risk of the sexual transmission of HIV in Ontario. It further emphasizes policy issues and problems arising at the nexus of science and criminal justice, in particular, those posed by the inconsistent use of complex scientific research by courts in deciding cases of alleged HIV non-disclosure. Finally, the report underscores that the criminalization of HIV non-disclosure hinders established HIV prevention efforts and contributes to HIV-related stigma.The report recommends that the Ontario Ministry of the Attorney General establish a consultation process to inform the development of policy and a practice memorandum regarding cases involving allegations of non-disclosure of sexually transmitted infections, including HIV.
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In England and Wales, criminal prosecutions for recklessly causing serious bodily harm by transmitting HIV have occurred since 2003. Understanding how people respond to the application of criminal law, will help to determine the likely impact of prosecution. As part of a wider qualitative study on unprotected anal intercourse amongst homosexually active men with diagnosed HIV in England and Wales, 42 respondents were asked about their awareness of criminal prosecutions for the sexual transmission of HIV, and how (if at all) they had adapted their sexual behaviour as a result. Findings demonstrate considerable confusion regarding the law and suggest that misunderstandings could lead people with HIV to wrongly believe that how they act, and what they do or do not say, is legitimated by law. Although criminalisation prompted some respondents to take steps to reduce sexual transmission of HIV, others moderated their behaviour in ways likely to have adverse effects, or reported no change. The aim of the criminal justice system is to carry out justice, not to improve public health. The question addressed in this paper is whether desirable public health outcomes may be outweighed by undesirable ones when the criminal law is applied to a population-level epidemic. Description from publisher website at: http://www.rhmjournal.org.uk/
In 1998, the Supreme Court of Canada ruled that a person living with HIV could be found guilty of aggravated assault if he or she did not disclose his or her HIV-positive status and exposed another person to a "significant risk" of HIV transmission. The notorious case--R. v. Cuerrier--involved an HIV-positive man and two women with whom he had intimate relationships involving unprotected intercourse. At the time the ruling, which imposed full legal responsibility for HIV prevention on people living with HIV/AIDS, raised many questions. Ten years later, many of those questions remain unanswered. In addition, a host of new issues have been added to the debate.
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younger than 14 years (at which time the AAP recommends full disclosure for all patients, with a preference for earlier disclosure as appropriate), full disclosure of the diagnosis may not be necessary for meaningful assent. Rather, it may be necessary only that the child and family be engaged in an established disclosure process. Such a process requires that the clinician or researcher obtaining assent be familiar with the child’s development and progress through the disclosure algorithm. In addition, the language to be used in the assent process should be discussed and agreed on in advance with the family. At age 14 years, most children ordinarily are able to understand the implications of an HIV diagnosis and are ready for full disclosure. Wider debate and consensus building about assent and disclosure are needed among agencies that sponsor pediatric HIV research in the United States and internationally. Financial Disclosures: None reported. Funding/Support: This Commentary was supported in part by Cancer Center Support Core Grant P30 CA21765 from the US Public Health Service and by the American Lebanese Syrian Associated Charities (ALSAC). Role of the Sponsors: The Cancer Center Support Grant and ALSAC fund St Jude’s infrastructure but had no role in the design and conduct of the study; the collection, management, analysis, and interpretation of the data; or the preparation, review, or approval of the manuscript. Additional Contributions: We thank Patricia Flynn, MD (Department of Infectious Diseases, St Jude Children’s Research Hospital), for information about the staged disclosure process at St Jude and for her critique of the manuscript. We also thank Sharon Naron, MPA, ELS (Department of Scientific Editing, St Jude Children’s Research Hospital), for editing and review of the manuscript. No compensation was received by those named herein. REFERENCES
Discourse across boundaries: On recontextualizations and the blending of voices in professional discourses
  • P Linnell
HIV and the criminal law
  • E J Bernard
Partners in health, partners in crime: Exploring the boundaries of criminology and sociology of health and illness
  • S Timmermans
  • J Gabe