Hiv Concerned About Confidentiality — Free SCA Practice Case
Newly registered patient with HIV concerned about confidentiality
Station Timer
Golden Minute
Initial Introduction
•Introduce yourself
•Ask an open question — "How can I help you today?"
•Listen — don't interrupt
•Catch early cues
Data Gathering
History, ICE & Diagnosis
Clinical Management
Diagnosis, Plan & Decisions
Safety Net
Follow-up & Close
Five cases are free: a live 12-minute consultation with an AI patient each, marked, and no card.
Materials for Candidate
Please review before starting the consultation
Full Name
Marcus Thorne
Age
34 years
Consultation Type
VideoAge
34
Reason for Encounter
"New patient registration review. The patient recently moved to the area. A letter from the local hospital's Immunology/Sexual Health clinic was received yesterday detailing his HIV diagnosis and current antiretroviral therapy."
Medical Records
- ●PMH: HIV (Diagnosed 4 years ago, CD4 count 650, Viral Load Undetectable).
- ●Medications: Biktarvy (Bictegravir/Emtricitabine/Tenofovir alafenamide) 1 tablet OD - supplied by the hospital.
- ●Allergies: NKDA.
Recent Notes
- ●Hospital Letter: "Marcus is fully suppressed on his current regimen. We will continue to monitor his HIV and dispense his antiretrovirals every 6 months. Discharged to GP for shared care of routine health, immunizations, and cardiovascular risk monitoring."
Patient Script
For the friend playing the patient role
Character Overview: You are Marcus. You are a primary school teacher who recently moved to this town for a new job. You are highly adherent to your HIV medication and physically very healthy, but you carry a heavy burden of internalised stigma regarding your diagnosis. You are polite but visibly tense during this consultation. You have actively avoided registering with a GP for the last two years because you don't trust the computer systems. You will not volunteer your specific fear regarding the reception staff unless the doctor explicitly asks what you are worried about or explores your reluctance.
Opening Sentence: "Hi Doctor. Thanks for seeing me. I recently registered with the practice because I moved for a new teaching job. I know the hospital sent you a letter about my HIV. I wanted to ask how this 'shared care' thing works, and more importantly, who exactly gets to see that letter."
History if Asked (Data Gathering Phase)
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Current Health & Hospital Care:
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"I feel completely fine. I take my pill every day, I never miss it. The hospital says the virus is 'undetectable'."
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"I get my bloods done at the hospital twice a year. I don't need you to prescribe my HIV meds, the hospital pharmacy posts them to me."
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Shared Care Expectations:
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"I just want to come to the GP for normal things, like if I get a chest infection or need a sick note. I want to keep my HIV completely separate at the hospital."
ICE — Ideas, Concerns, Expectations The patient does not raise any of the following unprompted. These surface only when the candidate directly explores the patient's perspective.
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Ideas: Marcus does not have a clear 'idea' about what is medically wrong — he knows he is well and his HIV is controlled. His concern is not clinical but systemic: he believes that GP computer systems are insecure and that non-clinical staff have unrestricted access to patient records. This belief was shaped entirely by his sister-in-law's behaviour as a GP receptionist.
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Concerns: Only reveal if the doctor explicitly asks what he is worried about or explores his reluctance: Reaction (The Reveal): You lean in and lower your voice. "Doctor, my sister-in-law used to work as a GP receptionist. She would come home and gossip about who was on antidepressants or who had chlamydia. I teach at the local primary school. If one of your receptionists or admins sees 'HIV' in big red letters on my file, and it gets out to the parents... my career is over. Can you please just delete the HIV diagnosis from your computer? You don't need it if the hospital is treating it."
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Expectations: Marcus wants reassurance that his diagnosis will be kept strictly confidential. Ideally, he wants the HIV diagnosis removed from the GP record entirely. Failing that, he wants a concrete explanation of exactly who can see what on the system — not vague reassurances, but specific details about role-based access controls. He also wants to understand what the GP actually needs to do as part of shared care, since he sees no reason for the GP to be involved at all if the hospital is managing everything.
If Asked — Medical History and Medications Actor guidance for when the candidate asks about medications, past medical history, or allergies.
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Biktarvy (Bictegravir/Emtricitabine/Tenofovir alafenamide): "It's one tablet, once a day. I take it every morning with breakfast — I've not missed a dose in years. No side effects really. When I first started it I felt a bit nauseous for the first couple of weeks, but that settled down completely. The hospital sorts the prescription — they post it to me every six months."
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HIV diagnosis and monitoring: "I was diagnosed about four years ago. I started treatment straight away. The hospital checks my bloods twice a year — they said my CD4 count is good, around 650 last time, and the viral load is undetectable. They said that means I can't pass it on, which was a big relief."
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Allergies: "No, no allergies to anything that I know of."
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Previous GP care: "To be honest, I haven't been registered with a GP for about two years. After I moved the first time I just never got round to it — well, I say that, but really I was avoiding it. I didn't want to go through this conversation. The hospital was handling everything so I just let it slide."
Social History and Lifestyle Impact
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Occupation and daily life: Marcus is a primary school teacher — Year 3 — and has just started at a new school in the area. He enjoys his work and is keen to establish himself in the school community. He lives alone in a rented flat. He is in a relationship but his partner lives in another city; they see each other most weekends.
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Lifestyle impact of the condition: The HIV itself causes no physical limitation whatsoever — Marcus is fit, active, and well. The impact is entirely psychological and social. He is hypervigilant about who knows his diagnosis. He has never told anyone at work. He chose to move to a new area partly for a fresh start where nobody knows. He describes the anxiety around confidentiality as constant: "Every time I have to give my medical details to anyone — a new dentist, travel insurance, anything — I get this knot in my stomach. Coming here today, I nearly turned around in the car park. I sat outside for twenty minutes before I came in." He has structured his life around keeping his diagnosis hidden, and this consultation is the moment where he feels most exposed.
If Asked — Associated Symptoms Actor guidance for when the candidate asks about symptoms relevant to HIV or general health screening. Marcus is well — the answers below are all consistent with a fully suppressed, healthy individual.
- ●If asked about weight loss: "No, my weight's been stable. If anything I've put on a couple of pounds since I moved — I've been eating more takeaways while I get settled."
- ●If asked about night sweats: "No, nothing like that."
- ●If asked about fevers or recurrent infections: "No, I hardly ever get ill. I had a cold back in January but that's about it."
- ●If asked about fatigue or tiredness: "No more than anyone starting a new job, to be honest. I sleep fine."
- ●If asked about skin rashes or lesions: "No, nothing on my skin."
- ●If asked about mouth ulcers or oral thrush: "No, my mouth's fine."
- ●If asked about cough or shortness of breath: "No, I'm pretty fit — I go running three or four times a week."
- ●If asked about bowel habit changes or diarrhoea: "No, all normal."
- ●If asked about mood or mental health: "I wouldn't say I'm depressed, but the whole secrecy thing wears you down. I've thought about counselling but then I'd have to tell someone else, wouldn't I? It's a bit of a catch-22." (Note: this is a mild pertinent positive — acknowledges psychological burden without introducing a formal mental health diagnosis.)
- ●If asked about sexual health or partners: "I'm in a relationship — my partner knows about the HIV, he's been really supportive. We're careful, but the hospital said because I'm undetectable it can't be transmitted. He gets tested regularly too."
- ●If asked about smoking: "No, never smoked."
- ●If asked about alcohol: "Socially — maybe a couple of pints at the weekend, nothing excessive."
- ●If asked about recreational drug use: "No, nothing like that."
- ●If asked about vaccinations: "I think the hospital mentioned something about that — hepatitis B maybe? I can't remember if I had it or not. I'd have to check with them."
- ●If asked about cervical/anal screening: "Nobody's mentioned that to me before." (Note: provides an opening for the candidate to discuss enhanced screening recommendations for people living with HIV.)
Responses to Management (The Negotiation Phase)
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If the Doctor agrees to just delete the diagnosis without counselling on the risks: "Oh, really? That easy? Thank you. So if I need antibiotics or anything in the future, it won't clash?" (Testing the doctor's knowledge of dangerous drug interactions).
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If the Doctor bluntly refuses to hide the diagnosis ("It's policy"): Defensive and panicked. "Then I want to deregister. I'll just use walk-in centres. It's my medical data, I have the right to say no, don't I?"
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If the Doctor explains Role-Based Access (only clinicians see the details): Skeptical but listening. "Are you sure? What stops an admin from just clicking into my consultation notes out of curiosity?"
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If the Doctor mentions drug interactions (e.g., steroid inhalers or antibiotics): "I didn't realize that. Even simple things from the GP can interact with my HIV pills?"
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If the Doctor acknowledges the emotional burden and offers support: Softens noticeably. "I appreciate you saying that. Nobody at the hospital really talks about this side of it — they just check the bloods and send me on my way. It would be nice to have someone I could actually talk to about it."
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If the Doctor offers a compromise (e.g., adding a confidentiality note or flag, discussing the practice's information governance): "That would actually make me feel a lot better. So you're saying there's a way to flag it so only the doctors see the detail? And the reception staff just see that I have an appointment, not what it's about?"
Mark Scheme
Domain 1: Data Gathering and Diagnosis
Domain 2: Clinical Management and Medical Complexity
Domain 3: Relating to Others
Clinical Learning Points
The Role of the GP in HIV Shared Care
- ●Under current BHIVA Standards of Care, the HIV clinic retains responsibility for antiretroviral therapy (ART), viral load monitoring, CD4 surveillance, and ARV dispensing. The GP is responsible for the holistic, longitudinal care of the patient — a role that becomes increasingly important as people living with HIV (People Living with HIV) age with a normal life expectancy.
- ●Cardiovascular risk monitoring is a core GP responsibility. HIV is an independent risk factor for cardiovascular disease through chronic immune activation and inflammation. Some ARVs (particularly older protease inhibitors and abacavir) also contribute to dyslipidaemia. BHIVA recommends annual cardiovascular risk assessment including BP, lipid profile, HbA1c, and smoking status. Note that QRISK3 does not include HIV as a variable, so calculated scores may underestimate true risk — GPs should consider a lower threshold for intervention in this population.
- ●Immunisations are a key GP-delivered intervention. Annual influenza vaccination is recommended for all People Living with HIV (classified as an 'at-risk' group under the Green Book). Pneumococcal vaccination should be offered as a single dose of the pneumococcal conjugate vaccine (PCV20), which replaced PPV23 for clinical risk groups in 2026; the Green Book lists HIV infection at all stages, regardless of CD4 count, as a clinical risk group. HIV is not among its examples of severe immunosuppression (the group given two doses), so Marcus needs one dose and no routine booster; BHIVA (2015) likewise advises a single conjugate vaccine dose irrespective of CD4 count and recommends against repeat dosing. Hepatitis B serology should be checked and the full vaccination course offered if non-immune — Marcus is uncertain about his hepatitis B status, and this should be pursued at a follow-up appointment. HPV vaccination is recommended by BHIVA for MSM living with HIV up to age 45 where not previously completed.
- ●Live vaccines (e.g., MMR, yellow fever, varicella) are contraindicated if the CD4 count is below 200 cells/μL. Marcus has a CD4 of 650 and is virally suppressed, so live vaccines can be administered if clinically indicated, ideally with specialist input.
- ●Cancer screening should follow national programmes. MSM living with HIV may benefit from anal cancer screening or HPV-related surveillance in some trusts — this should be raised sensitively, as Marcus indicates this has not previously been discussed with him.
- ●The GP also manages intercurrent illness, routine prescribing (with interaction awareness), mental health support, and is the natural home for preventive care and lifestyle review.
Drug Interactions and the Importance of the Medical Record
- ●The single most important clinical reason the HIV diagnosis and ARV list must not be deleted from the GP record is drug-drug interaction safety. This is the core argument for retaining the record and must be explained clearly and specifically to the patient.
- ●Biktarvy (bictegravir/emtricitabine/tenofovir alafenamide) is an integrase strand transfer inhibitor (INSTI)-based regimen without a pharmacokinetic booster. Its interaction profile differs from boosted protease inhibitor regimens, but clinically significant GP-relevant interactions still exist:
- ●Rifampicin: Contraindicated — potent CYP3A4 and P-glycoprotein induction significantly reduces bictegravir concentrations, risking virological failure.
- ●Carbamazepine, phenytoin, phenobarbital: Contraindicated — strong enzyme inducers that reduce bictegravir levels.
- ●Metal-containing antacids and supplements (calcium, iron, magnesium, aluminium): Chelate bictegravir and reduce absorption — must be separated by at least two hours, or taken with food under specific conditions per Liverpool guidance.
- ●Metformin: Bictegravir inhibits renal transporters (OCT2/MATE1), increasing metformin plasma levels — dose adjustment or monitoring may be required.
- ●St John's Wort: Contraindicated with all ARV regimens due to enzyme induction.
- ●Broader ARV interactions that GPs must understand — relevant because regimens change over a patient's lifetime, and future switches to boosted regimens (containing ritonavir or cobicistat) introduce additional high-risk interactions:
- ●Statins: Simvastatin is contraindicated with boosted ARVs due to massive increases in statin exposure, risking rhabdomyolysis. Atorvastatin is also affected and requires dose reduction. Pravastatin and rosuvastatin (at the lowest effective dose) are the preferred alternatives.
- ●Inhaled or intranasal fluticasone: Combined with ritonavir or cobicistat, markedly increased systemic steroid absorption leads to iatrogenic Cushing's syndrome and adrenal suppression. Beclometasone is the preferred inhaled steroid alternative in patients on boosted regimens.
- ●PPIs (e.g., omeprazole) with rilpivirine-containing regimens: Acid suppression prevents rilpivirine absorption, causing treatment failure and resistance — a common and preventable GP-level prescribing error.
- ●Clarithromycin: Interacts with multiple ARV classes; azithromycin is generally preferred for community infections.
- ●The Liverpool HIV Drug Interactions Checker (hiv-druginteractions.org) is the gold-standard resource and should be consulted before prescribing any new medication — including over-the-counter preparations — for any patient on ART.
- ●The argument for record retention also extends to future multi-morbidity: as Marcus ages, each new prescribing decision will depend on the interaction checker functioning against a complete and accurate medication record.
Information Governance, Confidentiality, and Practical Safeguards
- ●Marcus's request to delete his HIV diagnosis is understandable given his fears, but the GP should neither agree to delete the record nor dismiss the request bluntly. The optimal approach is to acknowledge the concern, explain the clinical risks of deletion, and offer concrete, practical safeguards.
- ●Role-Based Access Control (RBAC): GP clinical systems (EMIS Web, SystmOne) operate on RBAC, meaning different staff roles see different levels of information. A receptionist booking an appointment sees a restricted view — demographics and appointment slots — and does not have access to clinical consultation notes, diagnoses, or hospital letters unless specifically and explicitly granted clinical-level access. All access can be audited: unauthorised access to patient records constitutes a serious disciplinary offence and a potential criminal offence under the Data Protection Act 2018 and the Computer Misuse Act 1990.
- ●Confidentiality or sensitivity flags: Most GP clinical systems allow specific diagnoses, documents, or consultations to be marked with a restricted access or sensitivity flag (sometimes referred to as a sealed envelope or privacy policy). This allows the HIV diagnosis and the hospital letter to be masked from non-clinical staff while remaining fully visible to prescribing clinicians, ensuring safe prescribing and interaction checking. Offering this as a concrete, practical compromise is a key component of the optimal management plan.
- ●Summary Care Record (SCR): Marcus has the right to opt out of the SCR — the record shared with out-of-hours services, NHS 111, and emergency departments. The GP should counsel that opting out means emergency clinicians will not have access to his ARV list if he is incapacitated. This is his informed choice, but the clinical risks should be clearly explained. The SCR should be clearly distinguished from the GP clinical record, which remains within the practice.
- ●Caldicott Principles govern the handling of patient-identifiable information in the NHS. Patient information is shared on a need-to-know basis, and all staff with access to identifiable data have contractual confidentiality obligations. A straightforward explanation — "Everyone in this practice has signed a confidentiality agreement, and any breach would have serious professional and legal consequences" — is both accurate and reassuring.
- ●If Marcus threatens to deregister and use walk-in centres, the GP should explain clearly that walk-in centres have no access to his medication record, making unplanned prescribing against a background of unknown ART the least safe option for him.
Psychological Impact, Stigma, and Support
- ●Internalised stigma is one of the most significant determinants of quality of life for People Living with HIV and is frequently under-addressed in routine clinical encounters. Marcus's description of secrecy "wearing him down" and sitting in the car park for twenty minutes before coming in are direct cues that warrant empathic exploration, not merely surface acknowledgement.
- ●Marcus describes a catch-22 regarding counselling: wanting psychological support but fearing the disclosure accessing it requires. The GP should address this directly by explaining that counsellors and psychologists are bound by the same professional confidentiality obligations as doctors, and that accessing IAPT or specialist psychological services does not require disclosure of the reason to reception staff.
- ●Specialist support organisations worth signposting include:
- ●Terrence Higgins Trust (THT) — peer support, counselling, and advocacy for People Living with HIV.
- ●Positively UK — peer mentoring specifically for people living with HIV.
- ●Local peer support networks affiliated with the HIV clinic.
- ●The two-year avoidance of GP registration is itself a marker of the functional impact of stigma on health-seeking behaviour and should be recognised as clinically significant — not treated as a logistical oversight.
- ●The emotional dimension of the consultation often becomes more prominent once confidentiality fears have been addressed. The GP should remain attentive to this shift and allow space for it.
The U=U Message
- ●Undetectable = Untransmittable (U=U) is a landmark public health and clinical message supported by the PARTNER 1 and PARTNER 2 studies, which demonstrated zero linked HIV transmissions from virally suppressed individuals across nearly 77,000 acts of condomless sex. It is endorsed by BHIVA, UNAIDS, and the Lancet HIV Commission.
- ●The GP should use U=U proactively and positively to reinforce excellent adherence, normalise Marcus's health status, and directly counter internalised stigma. A statement such as "Your viral load is undetectable, which means you cannot pass HIV on to anyone — that is something genuinely worth holding onto" can be powerful in the context of this consultation.
- ●U=U supports framing HIV as a well-managed long-term condition comparable to controlled hypertension or type 2 diabetes — a framing that normalises the shared care relationship with the GP and helps reduce the psychological burden of the diagnosis.
Safety Netting and Follow-Up
- ●A follow-up appointment within two to four weeks should be arranged. This serves multiple purposes: completing hepatitis B serology, initiating cardiovascular risk assessment (fasting lipids, HbA1c, BP), reviewing immunisation status, and continuing to build the therapeutic relationship.
- ●Marcus should be advised to contact the practice or his HIV clinic before starting any new medication, including over-the-counter remedies, supplements, and medications from other providers (e.g., walk-in centres, dentists). The Liverpool HIV Drug Interactions Checker is also accessible directly to patients.
- ●Marcus should know that if he experiences worsening low mood, increasing anxiety, or greater isolation related to his diagnosis, he can contact the practice, self-refer to IAPT, or contact the THT helpline — without having to disclose his reason to reception staff.
- ●The follow-up also provides space to discuss anal screening and HPV awareness more fully if not covered in the initial consultation.
Common Candidate Mistakes
- ●Agreeing to delete the HIV diagnosis without explaining the drug interaction risks. This is clinically unsafe and represents the most significant negative indicator in the marking scheme.
- ●Bluntly refusing the request without exploring the underlying fear. Responding with "I can't do that, it's your medical record" without empathy or exploration risks Marcus disengaging or deregistering. The marking scheme rewards candidates who first explore the concern fully, then explain why the record is clinically necessary, and finally negotiate a practical compromise.
- ●Offering vague confidentiality reassurances (e.g., "Don't worry, it's all confidential") without explaining the specific mechanisms — role-based access, audit trails, sensitivity flags. Marcus's fear is concrete and based on lived experience; it requires a concrete and specific response.
- ●Failing to probe the ICE deeply enough — Marcus will not volunteer the sister-in-law story unless the candidate explicitly asks what has shaped his concerns about the GP record. Candidates who accept the surface-level anxiety without probing will miss the core of the consultation.
- ●Overlooking the psychological burden — focusing entirely on the practical and administrative aspects of shared care without acknowledging the emotional weight of living with concealed HIV stigma.
- ●Assuming all ARV interactions are identical — describing protease inhibitor interactions as though they apply without modification to Biktarvy demonstrates imprecise pharmacological knowledge. The correct approach is to explain Biktarvy-specific interactions clearly, while also noting that regimens change over time and future switches may introduce different interaction profiles.
- ●Failing to address the broader HIV management agenda — focusing exclusively on the confidentiality dispute without considering whether Marcus is up to date with routine HIV-related health maintenance.
Mapped to the RCGP curriculum topic: Infectious Disease and Travel Health.
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