Communication Skills: HIV Pre-Test Discussion

Potential OSCE station: You are the doctor in GUM clinic and you want to offer an HIV test to one your patients who has come in for a routine check-up. Please explain to the patient about the test and answer any questions he might have.

Starting the pre-test discussion
  • Introduce yourself
  • Wash your hands
  • Ask permission to discuss HIV testing
  • Explain that the discussion and results are confidential (a temporary set of notes will be used so that other health workers will not be aware of the result)
  • Can use ‘REEBBA’
‘REEBBA’
  • Reason for taking test
    • For example as routine for patient at GUM clinic or, if they have requested the test, ask if there is any specific reason why
  • Ever had a test before
    • If so ask when, and what the result was.
  • Exposure risk
    • It’s important to ascertain the patients exposure risk. See the table below for questions you can ask to identify high-risk activities.
    Risk assessment questions

    • Have you had any sexual experience that you would consider putting you at high risk of getting HIV?
    • When was the last time you had sex?
      • Male or female partner
      • Type of sex: oral, vaginal, anal
      • If anal: receiving or inserting
      • Contraception used
      • Condoms used
    • For men: Have you ever had sex with men?
    • How many partners have you had in the last 3 months?
    • Have your partners been tested for HIV?
    • Where were your partners from? (high-risk area?)
    • Have you had sex with someone who was HIV positive?
    • Have you ever worked as a sex worker?
    • Have you ever received a blood transfusion?
  • Basics of the test.
    • Explain how the test works, when they will receive the result and how effective it is
    • There are many different types of HIV test currently available in the UK (see table in notes at the bottom).
    • Commonly, Point of Care test:
      • Antibody test – shows body’s response to HIV virus
      • Finger-prick blood test
      • Results in a few minutes
      • Result is either negative or reactive (if reactive must confirm with an antigen blood test)
      • 99% accurate
    • Window period:
      • The test will not show whether you have contracted HIV within this period (either last 1 month or 3 months depending on type of test).
      • You should still have a test today but if you have had high-risk activity within the last 1 or 3 months then you should come back for another test if this one is negative.
    • Check understanding of what is meant by a positive and negative test result
    • False positives and false negatives:
      • Explain this can happen but is very rare
  • Benefits and risks of the test
    • Does the patient have an expectation of what the result will be?
    • Advantages of testing:
      • Prolonged good healthcare
      • Reduced anxiety
      • Treatable, manageable condition – not a death sentence
    • Disadvantages:
      • Stigma
      • Rejection from partners, family, job
    • How would they cope with a positive result?
    • Do they appropriate support in place for a positive result?
  • Agreement to test (consent)
    • Summarise what you have said
    • Check they have understood everything and ask if they have any questions
    • Consent: Are you happy to have an HIV test today?

Background
  • HIV is now a treatable condition affecting every 2.8 people per 1000 of the population. Despite this around a quarter of the people suffering with HIV are unaware they have the condition, leading to increased morbidity and mortality for themselves, as well as an increased risk of transmitting the condition to others. Therefore, early HIV testing is vital in both preventing transmission and improving health outcomes for those affected with the condition.

Who should be offered a HIV test?
  • There is national guidance on HIV testing which suggests that the following people should be offered HIV tests.
  • Universal HIV testing should be offered in these settings:
    • GUM clinics
    • Antenatal clinics
    • Termination of pregnancy services
    • Drug dependency programmes
    • Healthcare services for those treating people with TB, hepatitis B, hepatitis C and lymphoma
  • HIV testing should be considered in these settings where diagnosed HIV prevalence in the local population exceeds 2 in 1,000 population:
    • All men and women registering in general practice
    • All general medical admissions
  • HIV testing should also be routinely offered and recommended in the following patients:
Transmission Risks

From an HIV positive partner (without condom):

  • Receptive anal intercourse 1.4%
  • Insertive anal intercourse 0.1%
  • Receptive vaginal intercourse 0.08%
  • Insertive vaginal intercourse 0.04%
  • Oral sex < 0.01%
  • Needle sharing during IV drug use 0.6%
  • Needle-stick injury 0.2%
    • All patients presenting for healthcare where HIV (including primary HIV infection), enters the differential diagnosis
    • All patients diagnosed with a sexually transmitted infection
    • All sexual partners of men and women known to be HIV positive
    • All men who have disclosed sexual contact with other men
    • All female sexual contacts of men who have sex with men
    • All patients reporting a history of injecting drug use
    • All men and women known to be from a country of high HIV prevalence
    • All men and women who report sexual contact abroad or in the UK with individuals from countries of high HIV prevalence.

Types of HIV Test
3rd Generation Lab test 3rd Generation Point of Care test 4th Generation Lab test 4th Generation Point of Care test
Tests what? HIV antibodies HIV antibodies HIV antibodies and p24 antigens HIV antibodies and p24 antigens
Where available? Small no of GUM clinics and primary care Outreach, community settings GUM clinics, primary care Community (fairly rare)
Window period 3 months 3 months 11 days – 1 month 11 days – 1 month
How accurate? 98-100% Satisfactory for uncomplicated infection Can have high % false positives 99-100% Good, questions over sensitivity
How long to wait for results? 2-14 days 20-40 minutes 2-14 days 20-40 minutes

References, Useful Documents:
  1. NICE guidelines HIV testing
  2. HIV in the United Kingdom (2014 Report, Public Health England)
  3. Testing for HIV – Concise Guidance for Good practice series , October 2009, RCP

written by: naina_mccann, first posted on: 12/11/15; 12:20

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Comments:

Esko says...
Worth asking a tattoo history, especially tattoos received overseas!
POSTED ON: 30/04/17, 11:44

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