Communication Skills: Explaining a Diagnosis of Humman Immunodeficiency Virus (HIV)
HIV is a common condition, with over 100,000 people in the UK living with the disease. Up to a third of these do not know they have HIV and you may be asked to explain HIV to a patient with a new diagnosis.
OSCE scenario: This 25 year old man has recently been diagnosed with HIV and has some questions. Please discuss with him.
- Introduce yourself
- Wash your hands
- Ask permission to discuss his recent diagnosis with him
- Remind him that anything you discuss will be confidential
- Start by checking his understanding ‘tell me what you understand about HIV’
- HIV is a virus that attacks the body’s immune system
- Untreated it can be serious and cause you to suffer from infections
- However, good treatments are now available and most people living with the disease in the UK live a normal life-span
- If they ask about AIDS:
- AIDS is ‘acquired immunodeficiency syndrome’
- This is when the HIV virus has become very active in the body, usually because no treatment has been taken
- Increased risk of unusual, difficult-to-treat and potentially life-threatening infections
- There are lots of different ways you can contract HIV:
- Sexual intercourse with an affected individual
- Sharing of needles during intravenous drug use
- Transfusion of infected blood products (rare in modern medicine)
- Transmission from mother to baby
- Healthcare workers: needlestick injury, blood splash
- If there is a known method of transmission then explain to the patient that other people at risk will have to be tested for the condition
- The patient may not know how they contracted HIV – the test cannot tell them where or when they contracted it.
- May not have any symptoms
- Acute HIV can cause a fever, lymph node swelling and a generalised rash
- Chronic HIV symptoms are usually related to infections that you contract rather than underlying HIV
- There are three main-stays of treatment:
- Treatment of HIV virus
- Using antiretroviral therapy (ART)
- This is usually a combination of three medications (can sometimes be given in one tablet)
- Medications can have serious side effects but you will be informed about these and how to look out for them
- You will likely be starting ART soon and will be on medications for life
- Preventing infections
- Depending on your blood tests (CD4 count) you may be given medications to prevent you developing serious infections before you get them (primary prophylaxis – see Table A below)
- Depending on occupational and environmental exposure other treatments may also be given e.g. syphilis prophylaxis
- Treating infections
- There are different types of infection which will be treated with different types of medication (see Table B below)
- Some infections can cause an increased risk of cancer e.g. Kaposi’s sarcoma, lymphoma
- Your HIV care will be looked after by a specialised HIV team who will monitor your treatment and any potential complications
- Advise yes, the virus can be transmitted by sexual and blood-transmission, as well as vertical transmission (i.e. mother to baby) if they become pregnant
- To avoid this they should:
- Have protected sex (and inform their sexual partner)
- Not donate blood products
- Not share products that may contain traces of blood e.g. razors, toothbrushes, needles
- Comply with ARV treatment which will lower viral load and reduce transmission probability
- If they want to become pregnant reassure them that with well-managed HIV many women have HIV negative children
- Advise that anyone at risk of previous transmission should have an HIV test
- Ask if they have any further questions
- Offer leaflets/information as to where they can get further information e.g. counselling services
- Thank them for their time and give contact details of yourself/HIV team
Table A – primary prophylaxis in HIV
Condition |
Medication |
When to start |
When to stop |
Pneumocystis |
Co-trimoxazole |
CD4 < 200 |
CD4 > 200 |
TB |
Isoniazid |
+ve Tuberculin skin test but no signs active TB OR close contact with known active TB |
After 6 months |
Mycobacterium avium complex (MAC) |
Azithromycin once/week |
CD4 < 50 and no signs active MAC |
CD4 > 50 |
Influenza A + B |
Influenza vaccine |
All HIV patients |
|
Streptococcus pneumonia |
Pneumococcal infections |
All HIV patients, then repeat depending on CD4 count |
|
Table B – Infections in HIV
Class |
Agent |
Condition |
Treatment |
Bacterial |
Mycobacterium tuberculosis |
TB |
Anti-TB medication |
|
Mycobacterium avium complex |
Respiratory illness |
Azithromycin + ethambutol |
|
Salmonella |
Diarrhoea |
Ciprofloxacin |
Viral |
CMV |
Retinitis CNS disease |
Gangciclovir |
|
EBV |
Non-Hodgkin’s lymphoma |
CHOP ART |
|
Herpes zoster |
Shingles |
Aciclovir |
|
Hepatitis B |
Hepatitis, cirrhosis |
ART containing tenofovir and lamivudine (active against HBV) |
|
JC virus |
Progressive multifocal leucoencephalopathy (PML) |
ART |
|
Human herpes virus 8 |
Kaposi’s sarcoma |
ART |
Fungal |
Crytococcus neoformans |
Cryptococcal meningitis |
Amphotericin B + flucytosine à fluconazole maintenance |
|
Candida albicans |
Candida (oral, oesophageal, vaginal) |
Nystatin Fluconazole |
|
Histoplasmosis |
Rash, respiratory illness |
Amphotericin |
|
Pneumocystis jiroveci |
Pneumonia |
Co-trimoxazole |
Parasitic |
Toxplasma gondii |
Cerebral Toxoplasmosis |
Pyrimethamine + sulphadiazine + folinic acid |
|
Cryptosporidium |
Diarrhoea |
Start ART |
- BHIVA guidelines: www.bhiva.org/guidelines.aspx
- Oxford handbook of tropical medicine pages 69-150
- www.uptodate.com/contents/overview-of-prevention-of-opportunistic-infections-in-hiv-infected-patients