You are an FY2 in the GUM clinic.
Personal Details:
Name: David Lee
Age: 30
Medical Record:
Past medical history: None.
Regular medication: None.
Allergies: None known.
Notes:
Telephone consultation. David attended the GUM clinic two weeks ago with flu-like symptoms and swollen glands after a trip to Thailand. A full STI screen was performed.
Investigation Results:
HIV test: HIV antibodies positive
Chlamydia test: Negative.
Task:
1. Discuss test results.
2. Take a focused history and address his concerns.
3. Discuss the next steps in his management.
Opening Sentence: “Hello, Doctor, you’re calling with my test results?”
Open History (to give freely): “I’m feeling a bit better than I was; the flu symptoms have gone, but I’m still worried about the swollen glands in my groin and armpits.”
Cues to give: “My wife and I have been trying for a baby.”
ICE (Ideas, Concerns, Expectations):
Ideas: “I was hoping it was just a bad virus from the trip.”
Concerns: “Is it necessary to tell my wife about this? Can I still have children?”
Expectation: “I’m expecting you to tell me what’s wrong and what the treatment is.”
How to Act: You are in shock and denial at first, then you become very anxious and distressed, particularly about your wife and future children.
More History (only if asked): You travelled to Thailand with a friend a month ago. While there, you had a one-time, unprotected sexual encounter with a female prostitute. You have been married for three years and have had unprotected sex with your wife since you returned. You have no children yet, but have been planning to start a family. You are devastated and feel immense guilt.
Social History: You work as a sales manager. You have a good relationship with your wife, and you are terrified of what this will do to your marriage.
Questions to ask:
“Does this mean I have AIDS? Am I going to die?”
“Do I really have to tell my wife? It will destroy her.”
“Will we ever be able to have children now?”
Opening & Setting the Scene:
Hi Tom, thanks for arranging this appointment to discuss your results. Before we go through them, how have you been?
Breaking the News (SPIKES Protocol):
I have your results here. Unfortunately, the news is not straightforward.
While the tests for chlamydia, gonorrhoea, and syphilis were all negative, the test for HIV has come back positive. This result has been confirmed. This means you have HIV.” (Pause. Give the patient time to react. (Acknowledge the shock.)
Assessing Understanding & Concerns (ICE):
This is obviously a huge shock. What’s going through your mind right now?
What do you know about HIV? What does this diagnosis mean to you?
What is your biggest worry at this moment?
Sexual History & Partner Notification:
To help us understand the situation, I need to ask about your girlfriend.
How long have you been together?
Have you had any other sexual partners during that time, apart from the one-night stand you mentioned?
We will need to think about how to tell your girlfriend so she can get tested.
What are your thoughts on that
Explain the results:
David, thank you for taking my call. I have your test results here, and I’m afraid it is difficult news. The test for HIV has come back positive. This means you have contracted the Human Immunodeficiency Virus. I know this is a huge shock to hear, and I want you to know I am here to support you and answer all your questions.
(Pause, allow for silence and reaction.)
Addressing and answering the patient’s ICE:
A diagnosis of HIV today is very different from how it was 20 or 30 years ago. We have excellent, life-long treatments that can control the virus, keep your immune system strong, and allow you to live a long, healthy, and normal life. The key is starting and sticking with the treatment.
Next Steps:
The most urgent and important thing we need to discuss is your wife. Because you’ve had unprotected sex with her, there is a risk that she has been exposed to the virus. It is absolutely essential that she gets tested as soon as possible. If she does have the virus, starting treatment early is crucial for her health. I know this is an incredibly difficult conversation to have, but you must tell her. We have specialist health advisors who are trained to help you with this conversation, or you can do it together here in the clinic.
You also asked about having children. The answer is yes, you can still have children. When the HIV treatment has made the virus in your blood ‘undetectable’, it means you cannot pass the virus on to your wife through sex. Many couples where one partner has HIV go on to have healthy, HIV-negative children. This is something the specialist team will discuss with you in detail.
Next step
I am referring you immediately to the specialist HIV clinic. You will meet a team of doctors, nurses, and health advisors who will be with you every step of the way. They will do some baseline blood tests to check your immune system and the level of the virus, and they will start you on daily tablet medication.
We also have a duty to try to trace the contact you had in Thailand, which our health advisors can help with anonymously.
What is going on in your mind? Are there any questions so far?
Addressing ideas, concerns, and expectations: Correct the misconception that HIV is a death sentence. Emphatically and clearly explain the necessity of partner notification for his wife’s safety. Provide hope and factual information about having children (U=U: Undetectable equals Untransmittable).
Prescribing/referral/reassurance: The key action is an immediate referral to the specialist HIV service. Explain the role of the multidisciplinary team (MDT), including health advisors for partner notification. Reassure him that life can continue as normal with treatment.
What is scenario testing? This is a very challenging breaking bad news station that combines complex medical information with profound social and ethical issues. It tests the candidate’s ability to deliver a life-altering diagnosis, manage a patient’s acute distress, and firmly but empathetically handle the critical public health duty of partner notification.