NYSDOH Guidelines for Integrating Domestic Violence Screening into HIV Counseling, Testing, Referral & Partner Notification
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You are Here: Home Page> Revised Materials> Guidelines for Integrating Domestic Violence Screening into HIV Counseling, Testing, Referral & Partner Notification Guidelines for Integrating Domestic Violence Screening into HIV Counseling, Testing, Referral & Partner Notification
Introduction to Domestic Violence Issues.
Domestic violence is a significant, underlying cause of poor health and is well-documented
as a serious public health issue. Domestic violence can take many forms.
It can include physical, sexual, economic, emotional, social and/or psychological
abuse. In addition to being at increased risk for physical harm, victims
of all forms of domestic violence are at risk for other complications
which eventually lead to the need for medical care and other services.
The New York State (NYS) Office for the Prevention of Domestic Violence
(OPDV) uses a broad definition of domestic violence:
"Domestic violence is a pattern of coercive behavior which can include
physical, sexual, economic, emotional and/or psychological abuse exerted
by an intimate partner over another with the goal of establishing and
maintaining power and control."
Although the vast majority of reported victims of domestic violence are
female, providers should seek to identify and screen all potential victims
regardless of their gender, age or other demographic characteristics,
the gender of their partner(s) or the relationship between the potential
victim and abuser. Domestic violence occurs in all communities and can
be found in all types of relationships.
The HIV/AIDS epidemic has highlighted the role of health care providers
in early identification and intervention against domestic violence for
all individuals. Available data suggest that rates of domestic violence
among the gay, lesbian, bisexual and transgender (GLBT) populations are
comparable to the rates against heterosexual women (25%). Universal screening,
use of gender neutral terminology when referring to partners, recognition
that individuals who are GLBT may not identify or disclose as such, awareness
of GLBT community resources and sensitivity to the fact that individuals
who are GLBT who are requesting HIV testing may be in an abusive relationship
are recommended.
Outcomes of Domestic Violence
Physical injury or death
Complications of pregnancy and childbirth
Gynecologic problems
Sexually transmitted diseases
Human immunodeficiency virus
Chronic somatic disorder
Exacerbation of chronic medical conditions
Nonadherence with medical treatment
Depression, anxiety disorders and suicide
Eating disorders
Alcoholism
Substance abuse
Social isolation
There are numerous complications of domestic violence of which medical
providers, including those under whose auspices HIV counseling, testing,
referral and partner notification services are provided, should be aware.
Other outcomes of domestic violence that can affect physical health and
well-being of individuals with HIV, their children and others close to
them can include loss of housing, withdrawal of financial support, isolation
or loss of contact with and support from family and friends, custody retaliation
and withholding access to health care or medications.
Diagnosis of domestic violence is challenging because victims can present
with a variety of symptoms and physical findings. Studies show that individuals
often hope to be asked whether they have been abused and, if asked in
a caring and sensitive fashion, will often discuss their history of abuse.
Domestic Violence Risk Assessment as a Standard of Care.
Assessing risk of domestic violence is required in some settings in NYS
(i.e. hospitals, local departments of social services). The need for physicians
to recognize and treat family violence has been formally noted by the
American Academy of Family Physicians as an important role of family physicians.
Numerous organizations (i.e., the American Medical Association, the American
College of Obstetrics and Gynecology, the American College of Nurse Midwives)
have emphasized the need for routine assessment of all women seeking care.
In contrast to official recommendations, studies show that domestic violence
assessment is still not a routine medical practice.
Additionally, health care providers do not generally recognize men as
being subject to domestic violence, even when confronted by evidence of
physical or sexual assault. Further, health care providers generally do
not consider the possibility of domestic violence among gay or lesbian
relationships or with people who are of transgender experience or who
are bisexual. More often, injuries are incorrectly assumed to be the result
of "lifestyle choices."
Domestic violence risk assessment is a standard of care and should be
discussed in general intake procedures in all health and human service
settings, including counseling and testing sites.
As applied to HIV counseling and testing, domestic violence as a standard
of care means that a discussion of domestic violence is encourage during
pre-test counseling and domestic violence risk assessment is a require component
of post-test counseling of HIV-infected individuals.
HIV Counseling and testing offers a confidential, private and sage
setting for discussion of domestic violence
NYS regulations require that conversations with individuals seeking HIV
testing occur in confidential, private and safe manner. If communication
cannot occur in a confidential, private and safe manner, the discussion
should be deferred until these requirements are met. Since HIV counseling
and testing offers this confidential, private and safe setting, the HIV
testing session presents an ideal opportunity to discuss domestic violence
concerns.
Opportunities to Introduce Domestic Violence Questions
At Intake/Pretest Counseling
During Risk Assessment
During Sexual History Taking
During Discussion of How Individual Might React to Testing HIV
Positive
Whenever Partners are Discussed
During Safer Sex Discussions
At Posttest Counseling
All discussions related to domestic violence screening should be held
in private. In no instance should HIV counseling and testing or domestic
violence discussions occur in the presence of a parent, guardian, adult
or child who accompanies the individual seeking testing. Any individual
escorting the person seeking testing may be the perpetrator of domestic
violence or may be an individual whose presence inhibits the person seeking
testing from discussing domestic violence with the provider. Accompanying
individuals should simply be told that the provider needs to meet alone
with each person seeking testing and they should be asked to remain in
the waiting area. In addition, if a language interpreter is necessary,
such services must be provided by a professional or a party unknown to
the person seeking testing.
Introducing a Discussion of Domestic Violence Within HIV Counseling
and Testing.
HIV counseling and testing offers numerous opportunities
for providers to introduce the issue of domestic violence and to ask persons
seeking testing relevant screening questions.
Discussion of domestic violence concerns should be introduced during
intake for health and human services in a general fashion using simple
statements such as: "There are some questions that I ask all my patients because some of
them are in relationships where they are afraid their partners may hurt
them."
Simple questions can also be used when screening for risk of domestic
violence. The following two examples, below, were widely disseminated
in a screening tool developed jointly and widely circulated within NYS
through a collaboration between NYSDOH, OPDV, and the Medical Society
of the State of New York. They are consistent with screening questions
recommended by the American Medical Association and others.
"Do you ever feel unsafe at home?"
"Are you in a relationship in which you have been physically hurt or
felt threatened?"
"Have you ever been or are you currently concerned about
harming your partner or someone close to you?"
Additional questions should be used to further assess the extent to which
the individual may be subjected to various forms of abuse. These additional
questions are best tailored to each individual. Such questions may include:
"Have you ever felt afraid of your partner or ex-partner?
"Has a partner or ex-partner currently or ever:
Pushed, grabbed, slapped, choked or kicked you?
Forced you to have sex or made you do sexual things you didn't want
to?
Threatened to hurt you, your children or someone close to you?
Stalked, followed or monitored you?
When an individual informs the provider of a domestic violence concern,
provider support of the individual's decision to discuss domestic violence
is important. There are many ways that providers can express support and
concern. Support and concern can be expressed as follows:
"I believe you."
"I am concerned about your safety and well-being."
"I imagine this situation must be very difficult for you."
"You are not alone."
"The violence is not your fault and only (name of abusive partner)
can choose to stop his or her abusive behavior."
"No one deserves to be abused (hit, beaten, etc.)"
"There are options and resources available."
Referrals Should be Provided Whenever Domestic Violence or Risk
of Domestic Violence is Identified.
Domestic Violence Intervention Steps
Identify domestic violence
Assess risks and needs
Make a statement "That's not okay"
Provide referrals and limited assistance
Seek a signed release of information form to enable follow-up
Assure documentation of abuse
Follow-up, if able
Any time a risk of domestic violence is determined, providers should ensure
that referrals are provided for domestic violence support services and a
more comprehensive assessment of risks and needed services. Community resources
can include licensed domestic violence service providers, a domestic violence
hot line, licensed domestic violence programs (both residential and non-residential),
support groups for victims of domestic violence, general social services,
law enforcement agencies, emergency medical care and providers of legal
assistance. Health and human service providers should have available a list
of referral sources and telephone numbers for this purpose.
In summary, asking individuals about domestic violence can:
Help individuals get assistance and services.
Prevent severe injury and even death of abused individuals.
Provide individuals with an opportunity to discuss domestic violence
with someone who is receptive, supportive and able to assist.
Help the infected individual and provider work together to make a
decision as to whether HIV partner notification should proceed.
Save the person's life.
Discussion of Domestic Violence is Encouraged in Pretest Counseling.
Providers are encouraged to initiate discussion of domestic violence issues
in pretest counseling as part of an overall discussion of support systems
and what the client might anticipate if the test result is positive. This
strategy allows the individual to consider ramifications of a positive
result before receiving this information, enables the provider to anticipate
the need for any arrangements or referrals and provide more time for contingency
or safety planning, and offer the opportunity to intervene in cases where
domestic violence is present at the earliest possible opportunity, even
if the person tests negative. Early initiation of discussion of domestic
violence concerns also avoids broaching a sensitive topic at the same
time the individual learns of their positive status. The Medical Society
of the State of New York strongly recommends domestic violence screening
be done in the pretest setting with follow-up to be conducted in the posttest
counseling session(s). Similarly, the NYS OPDV also urges that domestic
violence screening take place during the pretest counseling session.
Domestic violence may be raised during HIV pretest counseling as follows:
"Being tested for HIV raises a number of important issues for you personally,
for other people in your life or for people close to you. I ask all my
clients about how a positive result would affect them and others."
"If your test comes back positive, we will talk more about letting your
partners know they have been exposed. We will take time to discuss steps
that you and I may need to take. We will need to safeguard your privacy,
your well-being, the well-being of your partner and contacts. We will
talk about whether if is safe for you and for your contacts if we notify
them that they may have been exposed to HIV."
Questions such as these below can be used in pretest counseling discussion
of domestic violence concerns:
"What do you imagine the response would be from your partner(s) or others
living in your household if they knew you tested positive?
"Have you ever felt afraid of your partner(s) or others in the household?
"Are you concerned about harming your partner or someone close to you
if you were to test positive?"
The required form for Informed Consent to Perform an HIV Test addresses
domestic violence and provides a domestic violence hotline number. This
information on the consent form can help to initiate discussion and will
facilitate access to domestic violence services by individuals who do
not confide domestic violence concerns to their care provider.
Domestic Violence Screening is Required During Posttest Counseling
of HIV-Infected Individuals.
Posttest counseling provides an additional opportunity to raise domestic violence issues, regardless of
the test result. Screening of protected individuals (i.e., individuals
who are HIV-infected) and their contacts for risk of domestic violence
related to HIV partner notification is a required component of
posttest counseling for HIV-infected individuals.
Domestic violence screening related to any partners named voluntarily
or known to the provider, takes place during posttest counseling during
the discussion of partner notification. The issue of domestic violence
screening is raised before partner names are elicited. It is the responsibility
of the health care provider providing posttest counseling or otherwise
discussing partner notification to engage HIV infected individuals in
a discussion of domestic violence risk associated with notifying each
individual partner. There is no criminal or civil liability for persons
who choose not to engage in partner notification activities.
General information concerning domestic violence screening is conveyed
before a specific discussion of names of partners. It can be introduced
as follows:
"It is important to let your partners know that they have been exposed
to HIV so that they can learn their own status and we hope you will help
with this. First, however, I want to make sure that notifying your partners
won't put you at risk. Nothing will happen to you if you decide it is
not safe for us to notify this person."
"A next step would be to try to let your partner and other contacts
know that they may have been exposed to HIV. Of course, it is very important
to try to stop the spread of HIV and help people get health care as quickly
as possible. When we make a notification, we do not tell them who may
have exposed them or even anything about the type of exposure."
Screening takes place on a partner-by-partner basis for any partners
voluntarily identified and for any additional partners or spouses known
to the provider. Simple screening questions, adapted from those already
in widespread use statewide, can be used as follows:
"What response would you anticipate from this partner if he/she were
notified of possible exposure to HIV?"
Have you ever been or are you currently concerned about harming your
partner or someone close to you?"
Follow-up questions that an be used to explore a history of domestic
violence and anticipated consequences of HIV partner notification are
as follows:
"Have you ever felt afraid of your partner or ex-partner?
"Has a partner or ex-partner currently or ever:
Pushed, grabbed, slapped, choked or kicked you?
Forced you to have sex or made you do sexual things you didn't want
to?
Threatened to hurt you, your children or someone close to you?
Stalked, followed or monitored you?
"Based on what you've just told me, do you think that the notification
of this partner will have a severe negative effect on your physical health
and safety, or that of your children or someone close to you?"
"Are you afraid of what might happen to you or someone close to you,
for example your children, if this partner were notified?"
Although there may not be previous incidents of severe domestic violence,
the notification of HIV exposure may spark an abusive reaction. Notification
may escalate serious verbal threats to physical violence or may increase
the severity of preexisting abuse. Other severe adverse outcomes may occur
that would negatively affect the health and safety of the HIV-infected
individual, his/her children or someone close to that individual. These
other severe adverse outcomes could include loss of housing, withdrawal
of financial support, custody retaliation or withholding access to health
care or to medications.
Medical providers, HIV test counselors, public health staff and others
will find that, in many cases, domestic violence is a difficult subject
to discuss. In some cases, a victim of domestic violence may refuse, out
of fear, cultural or individual concepts of loyalty to the batterer, lack
of self-awareness that they are in a domestic violence situation, or for
other reasons, to participate in the domestic violence screening. This
may be especially true when the person is under stress, and the screener
is an unfamiliar person not known to the victim. An individuals' failure
to cooperate in screening may raise a suspicion of domestic violence.
It is important for providers to know that abusers sometimes present themselves
as victims during the screening process and victims sometimes present
as abusers. It is also important for providers to remember that victims
don't readily identify themselves as victims. This can occur with both
heterosexual and GLBT victims. Skillful screening, perhaps by an experienced
domestic violence specialist, may help clarify these situations.
It is difficult to objectively assess or quantify the risk of domestic
violence; therefore the perception of the HIV-infected individual as to
whether a notification would result in domestic violence must be relied
upon as the best predictor of domestic violence. Providers should be aware
that it is also the case that many threatened and intimidated victims
of domestic violence may not be capable of communicating their risk to
the person conducting the screening or may be fearful of the consequences
if this information is revealed. Especially in the emotionally laden context
of a new HIV diagnosis, victims of domestic violence may not be capable
of discussing domestic violence risk or even have the self-awareness that
they are at risk.
Training programs can advance the skill and expertise of providers and
make them more comfortable in talking about domestic violence. In some
instances, one or more additional posttest counseling sessions may be
necessary to complete the discussion of partner notification and domestic
violence screening.
HIV-infected individuals should be assured that:
The information provided will be kept strictly confidential.
The confidentiality of HIV-related domestic violence information
is protected by law and regulations.
That such protected information will be used only to help make decisions
about whether partner notification should proceed and to offer referrals
for domestic violence services.
In no cases are names of HIV-infected individuals provided to partners
by public health staff.
Release Form Enables Communication
Use of a release form can enable public health staff to follow-up
directly with the protected individual, with his or her consent, and/or
his or her domestic service provider.
Use of a specific, signed release form for confidential domestic
violence information can enable communication between public health staff,
medical providers, protected individuals and domestic violence service providers.
Screening of Partners/Contacts is Also Important.
Providers must be sensitive to a risk for domestic violence against a partner when
that partner is notified. Domestic violence screening of the infected
individuals should elicit the infected individual's knowledge of the partner's
current situation, if it is known, when the partner is other than the
current partner. This can be done as follows:
"If you know whether our notifying a previous partner of their possible
HIV exposure might put them at risk of being harmed by of harming someone
they are currently involved with, it is important that you tell us about
it. We don't want to do anything that would put them in danger. Do you
know of any likely risk to this person?"
Domestic violence screening of the infected individuals should elicit
the infected individual's knowledge of the partner's current situation,
if it is known, when the partner is other than the current partner.
If it is learned that a partner may be or is currently known to be the subject
of domestic violence, this information is crucial for protecting the partner
from risk of domestic violence related to HIV partner notification and for
deciding whether or not any public health follow-up in relation to that
partner should proceed. If the notification should proceed, this information
will help guide how that follow-up should be conducted so as not to inadvertently
put the partner at risk.
Once notification occurs and the partner decides to seek or accept HIV
testing, the pretest counseling session for that partner will initiate
the domestic violence screening for that partner if he/she chooses to
be tested for HIV, as described above. Assessing the infected person's
own potential for violence towards a partner following being informed
of his/her own HIV status is also important, but is usually not possible.
Whenever PNAP/CNAP work with an infected individual to notify a partner,
they will confirm that a domestic violence screen of the infected individual
was conducted by the health care provider before they notify any partner(s).
Deferral of HIV Partner Notification.
Partner notification is deferred any time there is risk of behavior toward the HIV-infected individual
which may have a severe negative effect on the physical health and safety
of the HIV-infected individual, his/her children, or someone who is close
to them or to a partner/contact.
Domestic violence screening should result in domestic violence referrals
for all cases in which a risk, threat or history of any form of domestic
violence is identified (e.g. psychological, physical). However, HIV partner
notification may proceed in all cases except when screening reveals a
risk of behavior toward the HIV-infected individual which may have a severe
negative effect on the physical health and safety of the HIV-infected
individual, his/her children, someone who is close to them or to a contact(s).
Each HIV-infected individual for whom notification of a specific partner
is deferred based on a risk of severe domestic violence should be provided
with information enabling them to contact the NYS PartNer Assistance Program
(PNAP) or the New York City Department of Health and Mental Hygiene (NYCDOHMH) Contact Notification
Assistance Program (CNAP) at any point in the future.
These individuals should also be routinely offered the opportunity for
a follow-up appointment with the provider and/or PNAP/CNAP. Specifically,
individuals should be asked whether or not they would consent to follow-up
contact by public health staff for purposes of ascertaining the necessity
of continued deferral of partner notification. A specific plan reflecting
only those approaches that would constitute safe follow-up (i.e. alternative
telephone number or address) must be put into place. While it is recognized
that, in some cases, risk of severe domestic violence may never be resolved,
in other cases, steps can be taken to ensure safety, thereby enabling
partner notification to proceed.
Information that the domestic violence screen indicates a risk of severe
domestic violence is reported to the State Health Department on the Medical
Provider HIV/AIDS and Partner/Contact Report Form by the physician during
the required reporting of the name of the infected individual. When this
information does not appear on the Medical Provider HIV/AIDS and Partner/Contact
Report Form, it will be obtained from the physician when state or local
health department partner notification staff routinely contact the physician
to initiate follow-up. This will ensure that public health staff do not
initiate steps to notify the partner prematurely.
When the medical provider has deferred partner notification due to risk
of a severe negative effect resulting from domestic violence, public health
staff will follow-up with the provider in 30-120 days. During this period
there will be no public health follow-up with the HIV-infected individual
or any partners/contacts. The purpose of this contact is to ascertain
the current status and to reinforce the importance of reassessing domestic
violence risk and partner notification issues in subsequent contacts with
the infected individual to determine if partner notification can occur.
The existence of a signed release form will enable communication about
the status of domestic violence risk. If continued deferral of notification
beyond 120 days is necessary, public health staff will re-contact the
provider and no follow-up will take place with the infected individual
or any partners/contacts.
Ultimately, Part 63 regulations leaves the decision as to whether to
proceed with partner notification when partner notification has been deferred
to the professional judgment of the public health officer, in consultation
with the responsible physician, with input form the infected individual.
This decision involves balancing the potential risks of domestic violence
with the benefits of partner notification.
Health officers are encouraged to make such decisions in consultation
with the protected individual, his or her physician and, when a signed
release is present, the domestic violence service provider. Such consultation
maximizes safety of the HIV-infected individual(s) and/or any partners/contacts
while assessing when, or if, concerns about the safety of the HIV-infected
individual are sufficiently allayed to permit partner notification to
proceed.
Referral of HIV-infected individuals to HIV case management services
also assures ongoing discussion of HIV partner notification services,
even in those cases in which risk domestic violence has resulted in deferral
of notification. This helps ensure that HIV partner notification assistance
services can be accessed in the event that the previously identified domestic
violence concerns are resolved.
Domestic Violence Screening of Minors and Other Vulnerable Populations.
Domestic violence screening of minors needs to incorporate assessment
of potential violence from family members of the minor and of any partner
as well as from sexual and/or needle sharing partners. Risk of suicide
and potential for homelessness should be components of the screening process.
Even if a minor's parent or guardian consented to the HIV test, domestic
violence screening should still be conducted in a private, safe and confidential
fashion without any others, including the parent or guardian, present.
HIV partner notification activities in cases involving minors are carefully
planned. HIV partner notification does not require informing parents and
PNAP/CNAP services are available to minors without parental notification.
PNAP and CNAP staff have been trained to be particularly sensitive to
cases which present the possibility of parental or partner violence. PNAP
and CNAP have dealt with situations involving risk of domestic violence
for years and have worked successfully with minors. Notification takes
place in person, without the knowledge of any other individuals, such
as parents or guardians, partners, school officials or employers. PNAP/CNAP
work in partnership with providers to assure that physicians remain involved
and so as not to interfere with the patient-physician relationship. Providers
who are considering offering assisted notification to minors or otherwise
taking a more active role in notification are strongly encouraged to consult
with PNAP/CNAP in advance for assistance.
Other populations at significant risk for whom special care and precautions
in domestic violence screening and HIV partner notification are advised
include pregnant women, individuals who are legally unable to consent
(i.e. those deemed legally incompetent), seniors, individuals with physical
or sensory impairments (i.e. individuals who rely on an interpreter),
individuals who are unstably housed, individuals in residential or institutional
settings, immigrants and substance users (both in and out of treatment).
Consultation with skilled and experienced domestic violence specialists
and with PNAP/CNAP can help assure that necessary screening and notification
activities do not inadvertently put individuals at risk.
Confidentiality of HIV-Related Domestic Violence Information.
NYSDOH regulations specify that HIV-related domestic violence information
is covered by HIV confidentiality provisions which prohibit disclosure,
except as permitted pursuant to a specific release form. Presentations,
training and materials developed to implement Chapter 163 will highlight
this confidentiality protection to providers and others and reiterate
responsibilities under Public Health Law and regulations. Similarly, orientation
and training for public health staff reinforces this aspect. Unauthorized
disclosure could compromise an individual's safety. It is illegal and
punishable by a fine of up to $5,000 and a jail term of up to one year.
Revised: January 2002
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