2023.015 Orders for Control of Transmission of HIV and STDs in Texas

1.0 Purpose

This policy establishes the necessary steps and considerations a local health authority must take when pursuing a public health order or court order as a control measure for reportable HIV and STD infections. The policy directs managers of public health follow-up programs located in regional offices, major local health departments, and districts funded through the Texas Department of State Health Services (DSHS). DSHS considers an infection a public health threat when it meets certain criteria outlined in this policy.

This policy does not intend for HIV/STD public health follow-up programs in regional and local health departments to establish elaborate systems to detect and track incidents they see as markers for continued unsafe behaviors. Instead, this policy guides STD programs in determining how and when to apply control measures. Local and regional health departments may become aware of these situations through interaction with their own clients or when medical providers consult the Public Health Follow-Up (PHFU) program.

The objective of applied control measures is to provide effective disease intervention for individuals, reducing or eliminating the potential for further transmission. DSHS views the application of public health orders and court orders as a last resort to motivate an individual to participate in disease intervention and prevention.
 

2.0 Background

In Texas, facilities conducting exams or treatments for individuals with a communicable disease must provide counseling for preventing reinfection, preventing transmission, and necessary treatment. (Texas Health and Safety Code §81.083). DSHS HIV testing contracted facilities deliver counseling in accordance with the DSHS Program Operating Procedures and Standards (POPS) Chapter 2: Quality Assurance for Focused HIV Testing, Counseling, and Linkage to Care for HIV Prevention. Quality counseling and medical care increase positive outcomes for infection management to prevent further transmission.

As described in Texas Health and Safety Code §81.083, the infection a person acquires can present a threat to public health. Multiple factors may contribute to an individual's lack of participation in medical care and treatment. The continued transmission of an infection despite disease intervention attempts from the local health authority may warrant additional control measures. Texas law (Texas Health and Safety Code §81.083) gives the DSHS, or a health authority, the authority to order control measures for a person in order to manage the transmission of an infection when there is reasonable cause to believe the infection presents a threat to public health and attempts to intervene in the transmission of the disease using standard disease intervention activities have failed.
 

3.0 Authority

Texas Health and Safety Code §81.046, §81.051, §81.061, §81.082, §81.083, §81.109, Chapter 81, Subchapter G Court Orders for Management of Persons with Communicable Disease.; and 25 Texas Administrative Code, §97.8.
 

4.0 Definitions as Applied to Section Policy

Court Order – An order issued by a district court for the temporary or extended management of a person with a communicable disease.

Health Care Professional – A person whose vocation or profession relates to the maintenance of the health of another person and whose duties require a specified amount of formal education and may require a special examination, certificate of license, or membership in a regional or national association. 

Public Health Order – A document presented to a client for compliance control measures or disease intervention and treatment activities prior to requesting a court order.

Public Health Threat – A communicable disease an individual is living with or who the PHFU program reasonably suspects to be living with that is not managed by medical or disease intervention and presents an immediate threat to public health. 

Reportable STDs – An infection listed on the DSHS Notifiable Conditions list pertaining to the HIV/STD Section. The infections include acquired immune deficiency syndrome (AIDS), Chlamydia trachomatis, chancroid, gonorrhea, human immunodeficiency virus (HIV), and syphilis. 
 

5.0 Persons Affected

• Designated Health Authority (Local Health Agency)
• Local and Regional Public Health Follow-Up Programs
   

6.0 Policy

6.1 Responding to Referrals of Infections Representing a Potential Threat to Public Health

Public health follow-up (PHFU) programs accept referrals from health care professionals, STD or HIV case managers, and STD clinic staff. The PHFU program documents referrals according to this policy. The program manager or equivalent of the PHFU program has the responsibility for reviewing referrals over which the city, county, or regional health department has authority or for routing the referral to the appropriate PHFU program having authority.

Referrals, records, and information pertaining to disease investigations are confidential under Texas Health and Safety Code §§81.046 and 81.103. Health authorities do not disclose information regarding the source of the referral. Also, they do not disclose the information contained in the referral to the client under investigation, to anyone outside of the Section, or to the investigating PHFU authority.
 

6.2 Selecting the Appropriate Control Measure

The results of the investigation determine the type of control measure initiated. PHFU programs may apply the following control measures to a public health threat:

• Public health orders; and
• Court orders.

6.2.1 Identifying Characteristics Which May Lead to a Public Health Order Case Review

The PHFU program manager determines when the PHFU program initiates a public health order case review. A PHFU investigation is eligible for a public health order case review when it meets the following criteria:

• The infection is untreated or the client is not currently engaged in medical care sufficient for the management of the infection(s) and includes one of the following:
  • Currently pregnant;
  • Repeatedly named as a contact during a sexually transmitted disease partner elicitation interview for multiple disease intervention investigations; or
  • Knowingly exposed others to the reportable STD or HIV.

6.2.2    Public Health Order Case Review

The public health order case review fully informs those public health officials at the state and local levels of the particulars of the case before issuing a public health order. The local or regional health department only considers a public health order when standard disease intervention and other reasonable attempts to engage the person with medical care or treatment are not successful. The PHFU-contracted program has the responsibility of coordinating the review with local or regional health officials and the Section. PHFU programs coordinate with the Section by contacting the appropriate DSHS STD PHFU manager or managers. 

The Section gathers information on the PHFU program’s investigation process, provides the PHFU program with feedback on the investigation process, and assists in developing an action plan. The sharing of investigation process documentation follows appropriate security and confidentiality guidelines as outlined in Section Policy 2016.01, HIV/STD Section Confidential Information Security.   

The DSHS HIV/STD Section briefs and notifies appropriate DSHS upper management if the need arises. The Section does not issue a public health order. The informed decision to proceed with a public health order belongs to the local or regional health department.

The PHFU program establishes a procedure for informing the local health authority about the case. The local health authority issues the public health order through the local health authority, and only after investigating the PHFU-contracted program does it conduct the case review. The PHFU-contracted program manager informs the appropriate legal counsel of the decision to issue a public health order. The program and local health authority may use legal counsel to assist the program and the local health authority in drafting the language of the order (see Form 2023.015B, “Model Public Health Order”).

6.2.3    Issuing a Public Health Order

A public health order is a formal written notice of control measures issued by a local health authority and delivered to a client. The order warns the client that failure to comply with the conditions in the notice may prompt the local health authority to request that the district court issue an order against the client. The public health order:

• Is in writing, (except in urgent circumstances, delivered orally, followed by a written statement within three days) specific to the client, and identifies the infection that poses a health threat to others;
• Requires the client to cooperate with the local or regional health department in efforts to prevent further transmission of the infection;
• Requires the client to participate in health education, counseling, and treatment, and may require the client to accept referrals to medical care and social services programs;
• States the consequences for failing to comply with the order; and
• Was delivered by registered mail, requested a return receipt, and specified a timeframe to reply, either personally or by a representative of the department or local health department.

When the local health authority chooses to mail an order, the PHFU-contracted program conducts a follow-up visit after mailing the order if the client fails to respond within the time specified or fails to keep scheduled appointments. When performing a follow-up visit, reiterate to the client the importance of the order and what occurs when the client fails to comply with the public health order. The person performing the follow-up visit asks the client to sign a copy of the public health order. The client acknowledgment form provides the STD program with documentation that the client has received verbal instruction related to the public health order and understands the repercussions for failing to comply with the order. The PHFU-contracted program documents the client’s refusal to sign the control measure.

The PHFU-contracted program may issue a second public health order for a client who fails to respond within the time designated by the first order. The STD program follows up on the second public health order in the same manner as the first.

6.2.4    Court Orders

The issuance of a public health order must precede a court order. Local health authorities seek court orders only after public health authority interventions have failed. DSHS or PHFU programs consider using a court order as a last resort in the most serious cases.

The local health authority has the power to request a court issue an order for the management of a person with a communicable disease (Texas Health and Safety Code §81.151). Prior to referring the case to the local health authority, the PHFU program manager reviews the documentation for completeness and accuracy, ensures the PHFU program issues a public health order, and outlines the reasons for the unsuccessful intervention activities. The PHFU program follows the procedures of the local health authority for signature and routing to the appropriate level of management. Local health authorities must mail, or send via secure file transfer, a copy of the court order to the Section. For more information on court orders, refer to Texas Health and Safety Code, Chapter 81, Subchapter G, Court Orders for Management of Persons with Communicable Disease.
 

7.0 Additional Resources

13.0 Revision History