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

1. Identify domestic violence
2. Assess risks and needs
3. Make a statement "That's not okay"
4. Provide referrals and limited assistance
5. Seek a signed release of information form to enable follow-up
6. Assure documentation of abuse
7. 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.