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Contact Tracing

Contact tracing has not been widely used in the control of the HIV epidemic. Many public health professionals believe that a disease that has no treatment cannot be controlled by contact tracing. Civil libertarians and gay rights advocates fought reporting and contact tracing out of fear of social and economic reprisals against members of their groups. Diseases such as whooping cough and typhoid are controlled through contact tracing and patient counseling because they have no curative treatment. Concerns about discrimination should be addressed through antidiscrimination legislation, not through changes in disease control programs. Several states have used reporting and contact tracing since 1985, with good results and none of the problems that were predicted.[146]

Contact tracing for HIV has three objectives. The first is to explore the epidemiology of the disease. The statistics used in epidemiology may be a mathematical problem, but all analysis must begin with "shoe leather" epidemiology to collect data. Because the states with the majority of HIV carriers have not conducted contact tracing, HIV epidemiology is based on the theoretical projections drawn from nonrandom subpopulations rather than actual case counts.

The second objective of contact tracing is highly personalized education. As with other forms of public health education, general exhortations have little effect on individual behavior. Individuals become motivated to change their behavior when the threat becomes personalized. When contacts of an HIV carrier are notified that they have been exposed to the virus, they can no longer indulge in the self-denial that HIV is not their problem. Because the risk of HIV to heterosexuals has been downplayed, contact tracing often alerts unsuspecting persons to their exposure to HIV. This warning is valuable for HIV control because HIV is difficult to transmit. Many persons at risk will be warned before they have been infected.

The third objective is the converse of warning the unknowing contact: detecting irresponsible individuals who continue to engage in high-risk behavior. Public health officials have the authority under the U.S. Constitution to restrict the liberty of persons who pose a threat to the public health. This power has been used only sparingly for HIV control. As the epidemic spreads, however, there will be situations when it is necessary to restrict certain persons, such as prostitutes, who are repeatedly identified as contacts.

There has been a concerted effort to replace the term contact tracing with the more positive term partner notification. Partner notification is appropriate terminology for stable relationships. It does not fit so well when applied to a brief, anonymous encounter with a prostitute or to the denizens of a crack house. Partner notification and contact tracing are used interchangeably in HIV control.

The failure to require the reporting of HIV and conduct contact tracing saddles physicians with the burden of deciding whether to warn third parties whom their patients put at risk. This duty to warn is usually transferred to the health department when the physician reports a communicable disease. If the health department finds that third parties are at risk, health department personnel warn them. Physicians in states that accept and investigate reports of HIV infection discharge their duty to warn when they report the case to the health department.

Physicians in states that do not accept and investigate reports for HIV must either violate their patients' confidence or violate their duty to the public at large. The worst situation may be states that allow physicians to warn third parties but do not provide expert assistance. The physician may be sued for failing to warn, for warning the wrong person, or for defamation if the patient is not infected with HIV. (See Chapter 21.) In contrast, a properly written reporting statute can have the state assume the physician's duty to warn when the patient is reported to the health department and provide immunity from failure to warn lawsuits if the physician reports the case.[147]

[146]Potterat JJ; Spencer NE; Woodhouse DE; Muth JB: Partner notification in the control of human immunodeficiency virus infection. Am J Public Health 1989; 79(7):874.

[147]Richards EP: Colorado public health laws: A rational approach to AIDS. Dev U L R 1989; 65:127.

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