Where you are:
FY2 in GP surgery.Who the patient is:
George White, 25-year-old man, who has come for his reports.Other information you have:
Presented with generalised lymphadenopathy 2 weeks ago. Blood test was done, FBC, LFT, U&Es, Urine chlamydia screen was normal. HIV antibody and p24 antigen test are positive. He is diagnosed with HIV infection and has been referred to GUM clinic.What you must do:
Talk to the patient, discuss results, address his concerns, and manage the patient.
Patient information: (The positive findings for candidates to simulate)
- Your name is Gorge White; you are a 25-year-old gentleman.
- Last week you came to the GP to be tested for HIV because you had casual sex when you visited Thailand 3-4 weeks ago.
- You have noticed that you have swellings/lumps in your neck, armpit, and groin 2 weeks ago.
- You had unprotected sexual intercourse with a male partner.
- You are married.
- After returning from Thailand, you had unprotected sexual intercourse multiple times with your wife.
- You had gone for a business trip to Thailand.
- You work as an IT engineer.
- You are otherwise fit and well.
- You are not on any other medication.
- You are scared to tell your wife that you have been diagnosed with HIV.
- You feel like your wife will divorce you if you tell her you have a HIV infection.
- You have been married for 3 years.
- You live only with your wife.
- You have got no known allergies.
Questions:
- Should I inform my wife?
- Can you help me tell my wife?
- Can I have children with HIV?
- Is there any chance I could have transmitted the HIV to my wife?
- Can we repeat the test?
- Should I inform my employers?
Emotions and attitude:
- Very worried
- Afraid that your wife will leave you if she finds out that you contracted HIV.
GREET
Dr: Hello, I am Dr (name), one of the foundation doctors in this GP surgery. Can you please confirm your name and age for me?
Pt: Hello Dr, I am George White, 25 years old.
Dr: Nice meeting you George. I have been asked to come and talk to you about your test results. Has anyone explained the test results to you at all?
Pt: No.
Dr: Okay, don’t worry. Would it be alright if I ask you a few questions before I go on to disclose the report?
Pt: Sure doctor. That’s fine.
P1- FOCUSED HX
Dr: Was there any particular reason you wanted to get tested in the first place?
Pt: I noticed some lumps and bumps.
Dr: Alright, can you tell me more about it?
Pt: They are in my neck, groin, and armpits.
Dr: When did you notice them?
Pt: A couple of weeks ago.
Dr: Has it changed?
Pt: No.
Dr: Is it painful?
Pt: No.
Dr: Have you done anything about it?
Pt: I came to my GP, and he ordered some tests for STIs.
Dr: Alright, so apart from lumps, any other symptoms at all?
Pt: I’m not sure.
Dr: Any fever or flu-like symptoms?
Pt: No.
Dr: Any sore throat or cough?
Pt: No.
Dr: Any night sweats? Did you notice any weight loss? Any loss of appetite?
(FLAWS)
P: No.
Dr: Do you feel tired recently?
Pt: No.
Dr: Any Joint pain? Muscle pain?
Pt: No.
P2- PAST HX
Dr: Have you had a similar kind of problem in the past?
Pt: No.
Dr: Have you been diagnosed with any long-standing health problems in the past?
Pt: No
MAFTOSA + DESA
Dr: Are you on any medications currently?
Pt: No.
Dr: Any allergies from any food or medications?
Pt: No.
Dr: Has anyone in the family been diagnosed with any medical condition?
Pt: Yes/No
Dr: Have you travelled outside UK recently?
Pt: Yes, I have been to Thailand about 3-4 weeks ago.
Dr: What do you do for living?
Pt: IT engineer.
Dr: If you don’t mind, I need to ask you some personal questions. Can you tell me if you are sexually active?
Pt: Yes.
Dr: Do you have a stable partner?
Pt: Yes, I am married.
Dr: Do you have any other partner?
Pt: Yes doctor last time when I went to Thailand I had casual sex with someone there.
Dr: Do you practice safe sex, like using condoms?
Pt: No, I don’t like how they feel.
Dr: Did you practice unprotected sex with your wife after trip?
Pt: Yes, multiple times.
Dr: What’s your sexual preference?
Pt: I am bisexual.
Dr. Okay. A few more things regarding your lifestyle, do you smoke?
Pt: Yes/No
Dr: Do you drink alcohol?
Pt: Yes/ No
Dr: By any chance, do you take any recreational drugs?
Pt: No.
Dr: I would like to do a GPE, take your vitals, and examine your lumps and bumps. Is that OK with you?
Pt: Okay doctor.
Dr: Are you happy for me to explain the results to you now?
Pt: Yes.
Dr: Do you want anyone to be by your side now whilst we discuss the results?
(Support)
Pt: No.
Dr: Do you have any idea why are you having these lumps and bumps? (IDEA)
Pt: No.
Explaining / disclosing the results:
Dr: So we screened you for STIs and most of the tests came back normal. However, there are some bad news as well. PAUSE
Pt: What happened doctor?
Dr: I am sorry to say, that the HIV test came back positive, which means that you’ve got HIV.
PAUSE (Patient might be quiet, might be shocked)
EVE Protocol (Acknowledge emotion/ Reflect/ Show empathy)
Dr: I can see that you are really shocked by this news./ You were not expecting this news./ I am so sorry to tell you all this. (Acknowledge the emotion).
Explain the diagnosis
Dr: Are you aware of what HIV means?
Pt: Yes/ No
Dr: HIV (Human Immunodeficiency Virus). It’s a virus that damages the cells in the immune system and weakens your ability to fight infections.
Pt: Is HIV and AIDS same thing?
Dr: No, AIDs (Acquired Immunodeficiency Syndrome) is a state of very low immunity when you become susceptible to threatening infections. This state develops after the HIV virus has destroyed the immune cells.
Pt: Why do I have HIV?
Dr: It is transmitted through unprotected sex or infected needles. In your situation, it’s likely you got it from the person you had sexual intercourse with in Thailand.
Pt: Could it be a false report? Can we do the test again?
Dr: Well you are right. Sometimes the report can be false, but we have already confirmed by testing your sample again. We always check it twice before telling the patient.
Management: ARMMS
ADVICE:
Pt: Should I inform my wife?
Dr: Yes, I would advise you to inform your wife that you are HIV positive so that she may come and get tested. You should also inform any sexual partners you may have been in contact with recently about your current condition and encourage them to get tested.
Pt: I am afraid she might leave me. Can you help me tell my wife?
Dr: I understand it’s difficult. We can inform her through a partner notification program, by which we invite partners anonymously to come and get tested.
Please note: If patient refuses, please gently encourage them to tell their partner. Explain that whilst nobody can force him to tell her, he could be criminally liable of reckless transmission of HIV if he continues to have unprotected sex with his partner whilst knowing he has HIV. Nevertheless, we will not inform her without letting him know first. (Do it in a very nice manner, don’t threat, try to convince. Here it is your moral duty to convince the patient to do the right thing.)
Don’t talk in a judgmental way, don’t threaten.
RISK FACTORS:
Pt: Is there any chance I can transmit the HIV to my wife?
Dr: Yes. If you have unprotected sex. So, we always advise HIV patients to avoid sex for the first 6 months of treatment whilst the virus is still detectable, or if you have sex it’s better to use condom. (Avoid sharing needles if he gives you Hx of iv drug abuse and avoid blood transfusion).
Pt: Can I have children with HIV?
Dr: Yes you can, but we would need to take measures to prevent mother to child HIV transmission. Transmission from mother to baby during pregnancy, birth or breastfeeding is possible.
MEDICATIONS
Dr: Do you have any concerns at this point?
Pt: What are you going to do for me?
Dr: We will refer you to the GUM Clinic. In the GUM clinic, once you are there, they are going to start you on some medications for HIV to lower the viral load in your blood. You will be given antiretroviral medication- one or two tablets to be taken throughout your life. You’ll have regular blood tests to monitor the progress of the HIV infection before starting treatment. (HIV viral load test and CD4 cell count)
Note: Most people taking daily HIV treatment reach an undetectable viral load within 6 months of starting treatment.
Pt: Can I have a normal life?
Dr: If you manage your condition properly by taking your medicine correctly and avoiding illness, you should be able to live a near-normal life.
Pt: Should I inform my employers?
Dr: There’s no legal obligation to tell your employer you have HIV, unless you have a frontline job in the armed forces or work in a healthcare role where you perform invasive procedures.
Multidisciplinary
Being diagnosed with HIV can be extremely distressing, We can provide you with counselling so you can fully discuss your condition and concerns.
Safety netting
Dr: Alright, if you are feeling unwell, please come back to us immediately.
Follow up appointment within 2 days specific for HIV.
Leaflets and information on where patient can get support from.