Cases/Sexual Health

Man Worried After Condomless Sex Two Nights Ago — Free SCA Practice Case

Man worried after condomless sex two nights ago

Station Timer

12:00

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

12:00

Golden Minute

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Materials for Candidate

Please review before starting the consultation

Patient Profile

Full Name

Anton Wilkes

Age

30 years

Consultation Type

Telephone

Age

Situation

Telephone Consultation. Same day appointment booked by the patient.

Reason for Encounter

"Would like an HIV test today after unprotected sex."

Medical Records

●PMH: Chlamydia 5 years ago, treated. No other conditions.
●Medications: None on repeat.
●Allergies: NKDA.
●Immunisations: Childhood schedule. Hepatitis B not recorded.
●Social: Procurement manager. Lives with a flatmate.

Recent Notes

●Sexual health clinic letter, 14 months ago: Full screen. HIV, syphilis, chlamydia and gonorrhoea negative.

Patient Script

For the friend playing the patient role

Character Overview: You are Anton Wilkes, a 30 year old procurement manager for a company that supplies equipment to hospitals. You rent a flat with your flatmate Nuno and you are single. You have sex with men, and you have been using a dating app since a relationship ended about five months ago. Two nights ago you went home with a man you had just met, and you did not use a condom. You have barely slept since. Today is Friday. You looked at the sexual health clinic website this morning, and it says walk in sessions run on Mondays only, with booked appointments full until next week, so you plan to go on Monday, and you want to know where you stand before then. You are articulate and organised, and you speak quickly when you are anxious. You are embarrassed rather than ashamed, and you want practical answers, not a lecture. You assume a blood test today will give you an answer.

Opening Sentence: "Hello, doctor, sorry to ring like this. I had sex without a condom with someone I'd just met, two nights ago, and I'd like an HIV test today if that's possible. I won't be able to relax until I know."

History if Asked (Data Gathering Phase)

●What happened: "I met a man on a dating app and went back to his place. We had anal sex without a condom. I was the receptive partner and he finished inside me. We also had oral sex. I'd had a few drinks, and it just happened. I haven't stopped thinking about it."
●When: "It was about eleven at night, the night before last, so Wednesday. It's Friday afternoon now, so roughly forty hours ago."
●The other man: "I only know his first name, Jarrod. He said he was 'clean', whatever that means, and I didn't ask anything else. He didn't mention PrEP or any medication. I think he has deleted his profile, because I can't find it. I've no number and I don't know where he works."
●Any other sex since: "No. Nothing in the last few days apart from that night."
●Before that: "I had a boyfriend until about five months ago. Since then there has been one other man, about two months ago, and we used condoms and nothing went wrong. Nobody else."
●Drugs and injecting: "I've never injected anything and I don't take drugs. I have never been to a chemsex party. Alcohol only."
●Last tests: "I had a full screen at a sexual health clinic about fourteen months ago, when the relationship started. Everything was negative. I had chlamydia once, about five years ago, and it was treated."
●Symptoms now: "None. No discharge, no pain when I pass water, no soreness or sores down below, no rash, no sore throat, no fever and no swollen glands. I feel fine, just very anxious."
●Hepatitis B: "I think I had hepatitis B injections years ago for travel, but I don't have any record and I couldn't tell you how many I had."
●Plans so far: "I looked at the sexual health clinic website this morning. The walk in is Mondays only and the booked appointments are all taken until next week. So I was going to go on Monday and get it all sorted then. I haven't rung anyone else, I assumed it would be the same wherever I went."
●Availability today: "I work from home today and I have no meetings after one o'clock. I can travel anywhere today, whatever it takes. I have a car."

Ideas, Concerns, Expectations

Gating note: Anton does not volunteer any of this. Each part comes out only when the doctor asks what he thinks is going on, what is worrying him, or what he was hoping for from the call.

●Ideas: He thinks a blood test today will show whether he has caught anything. A friend once told him it can take months to show, but he assumes the modern tests are quicker. "Surely there's a quick test now? I thought the results come back the same day." He has never heard of tablets that can be taken after sex to prevent HIV, and he assumes that nothing can be done before the clinic opens on Monday and that Monday is soon enough. "It's only a few days. Monday should be fine, shouldn't it?"
●Concerns: He is frightened that he has HIV and that he has been careless. He is worried about having to tell his parents, who fret about him, and about being judged by hospital or clinic staff. He is worried about sitting in a busy hospital waiting room at the weekend and having to explain himself to strangers. He has told nobody, not even Nuno. If asked about work, he is not worried about his employer, but he does not want it to appear anywhere that his employer or a private insurer can see. "I don't want this turning up somewhere it shouldn't."
●Expectations: He expects a blood test and a result today, or at least over the weekend. If that is not possible, he wants a clear plan he can follow. "I just want to know what I'm supposed to do."

If told there is treatment that can be started after sex to prevent HIV: "I didn't know that was a thing. Why does nobody tell you that?" He asks how well it works and whether it is too late.

If Asked: Medical History and Medications

Gating note: Anton answers each of these plainly when the doctor asks about it.

●Health problems: "Nothing. I'm fit and well. No kidney or liver problems, no hepatitis, and no previous HIV tests that were anything but negative."
●Medicines: "I take no prescription medicines. I take a daily multivitamin with iron and zinc in it, and I take an antacid, the liquid kind, about twice a week for heartburn."
●Allergies: "None that I know of."
●Alcohol and smoking: "About fifteen units a week, mostly at weekends. I don't smoke."

Social History and Lifestyle Impact

●Home: Anton lives with his flatmate Nuno, who knows nothing about this. His parents live in another part of the country and he is close to them. He is out to his friends and to his parents, who are supportive. He has not told anyone about the other night.
●Work: He is a procurement manager. His employer knows nothing about this.
●Dating: He has had a handful of partners in the last two years and used condoms most of the time. He has never taken anything to prevent HIV before sex and did not know it was available.

If Asked: Associated Symptoms

Gating note: Anton answers these only when asked. Every one is negative.

●If asked about a flu like illness, fever, rash, sore throat or swollen glands: "No, nothing like that."
●If asked about discharge, pain passing water, anal pain or bleeding, or sores: "No, nothing at all."
●If asked about jaundice, dark urine or yellow eyes: "No."

Responses to Management (The Negotiation Phase)

●
If the doctor explains that medicines to prevent HIV can be started after sex and that he should start them today:
- ●Reaction: Surprised, then relieved. "There are tablets for that? How well do they work? Is it a hundred per cent?" If told they are very effective when started early but are not a guarantee: "Okay, I can live with that. Is it too late, though?" If told that the cut off is 72 hours and sooner is better: "So forty hours, I'm cutting it close. Monday is way past that, isn't it?" He agrees to go as soon as he is told it is urgent.
●
If the doctor arranges where and when he can be seen:
- ●Reaction: Practical. "I can go right now. Where do I go and do I just turn up?" If the doctor suggests the Monday walk in, an appointment tomorrow, a routine slot, or waiting for a call back, he pushes back: "You said it has to be within 72 hours. Isn't that too late?" If told the hospital emergency department can start the medicines when the clinic is closed: "A&E? Will they know about this?" He asks whether his employer could see it, and is reassured if told clinic attendance is confidential.
●
If the doctor discusses the blood test he asked for:
- ●Reaction: Puzzled. "So can I just have the test today?" If told that a test today only shows the starting point and cannot rule out a recent infection: "So it's useless today?" If told the final test is at least six and a half weeks after finishing the course, around ten to twelve weeks after the exposure: "Twelve weeks? That's a long time to wait. Can I not test sooner?" If told that earlier tests are not final and that he will be given the exact date for the one that counts: "Okay, as long as someone gives me a date."
●
If the doctor explains how long the tablets last and how to manage them day to day:
- ●Reaction: Practical and slightly anxious. "A whole month? Every single day? Will they make me ill?" If told to avoid antacids and supplements containing iron or zinc around the dose, or that the prescriber will check his medicines: "Right, so my multivitamin and the heartburn liquid need to be sorted out first." If told to avoid missed doses: "I'll set an alarm."
●
If the doctor raises ongoing prevention or condoms:
- ●Reaction: Open. "Is there something I can take regularly so I don't have to go through this again?" If told it is available from sexual health clinics: "That sounds sensible. I'll ask when I'm there." If told to use condoms until the final test: "Understood."
●
If the doctor gives safety netting or arranges support:
- ●Reaction: Wants specifics. "What would I be looking out for, and how soon? What if I feel ill at the weekend, when the clinic is shut?" If told about fever, rash, sore throat or swollen glands in the first few weeks, or severe sickness from the tablets: "Okay, and who do I ring?" If the doctor offers a follow up call today to check that he has been seen: "Yes, please. I'd really like that." If the doctor offers no plan for today and only says he can come back on Monday or in a week or two: "That's too late. You said it has to be within 72 hours."

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 16 indicators checked+0−0

Positive (0/8)

Negative (0/8)

Domain 2: Clinical Management and Medical Complexity

0 / 24 indicators checked+0−0

Positive (0/12)

Negative (0/12)

Domain 3: Relating to Others

0 / 14 indicators checked+0−0

Positive (0/7)

Negative (0/7)

Clinical Learning Points

The Core Dilemma and the Model Plan

●Anton asks for an HIV test, but a test today answers the wrong question. At about 40 hours after condomless receptive anal sex with a man of unknown HIV status, the time critical decision is whether to start HIV post exposure prophylaxis (PEP), which is only useful if started within 72 hours and works best the sooner it is started. It is Friday, and he plans to wait for the sexual health clinic's walk in on Monday, which falls more than four days after the exposure and outside the 72 hour window, so the decision is to start PEP today.
●The model plan has five parts. First, take a focused risk history. Second, recognise that this exposure meets the BHIVA indication for PEP. Third, ensure he is assessed and starts treatment today, at a sexual health clinic or an emergency department, without waiting for results or for the partner to be traced. Fourth, explain the baseline and follow up tests, including a final HIV test at least 45 days after finishing the course. Fifth, give practical advice for taking the course, condoms until the final test, prevention afterwards and specific safety netting.
●Acceptable alternatives that also pass: phoning the clinic or the on call HIV clinician in front of him and then handing over; sending him to the emergency department if the clinic is closed; or starting PEP in the practice where the practice stocks it and the clinician is competent to prescribe it. All reach the same endpoint, which is a first dose today. Waiting for the Monday walk in, a routine appointment, a call back tomorrow or a test first is not acceptable.

Why This Exposure Qualifies for PEP

●The BHIVA UK guideline for HIV PEP (2021, with a 2023 amendment) recommends routinely offering PEP after receptive anal intercourse with a partner of unknown HIV status, or known to be HIV positive with an unknown or detectable viral load. Insertive anal sex with a partner of unknown status is a "consider" category. In the UK, men who have sex with men count as a high prevalence group (over 1 percent) for this purpose; where the partner is from a low prevalence group, PEP is not recommended after receptive anal sex.
●The risk of any single episode is low in absolute terms. The guideline gives an illustrative calculation for receptive anal sex with ejaculation with a man of unknown status in London of roughly 1 in 2,000. The guideline's per act figures, from a partner not on suppressive treatment, are highest for receptive anal sex with ejaculation (about 1 in 65), which is why PEP is recommended despite the low overall figure.
●Since the 2021 guideline, risk for unknown partners is based on the prevalence of detectable HIV viraemia, not the prevalence of HIV, because most people with diagnosed HIV in the UK are on treatment with an undetectable viral load and cannot pass it on.
●PEP is not recommended if the partner is known to be HIV positive, on antiretroviral treatment for at least 6 months with an undetectable viral load and with good adherence. It is not recommended for oral sex, including with ejaculation.
●Ask whether the patient himself takes PrEP. According to the BASHH and BHIVA clarification, a person on oral PrEP who has taken it appropriately and takes a double dose within 24 hours does not need PEP. Anton is not on PrEP.

Timing: Today, Not Monday

●Start PEP as soon as possible, preferably within 24 hours. The guideline does not recommend starting beyond 72 hours. Anton is at about 40 hours on Friday afternoon, so the 72 hour limit falls late tomorrow night, before the clinic's Monday walk in opens. Monday is more than four days after the exposure, so that plan would miss the window.
●Do not delay for baseline blood results. Do not delay to establish the partner's status; the guideline asks for proactive attempts to find it but says this must not hold up PEP. Here the partner cannot be traced, which does not change the decision.
●The guideline recommends 24 hour access and advice from an experienced HIV clinician for complex cases. Practice arrangements for PEP vary across England. Know your local pathway, and if it is unclear, the emergency department is the safe default.

Regimen and Practicalities

●The first line regimen is tenofovir disoproxil 245 mg with emtricitabine 200 mg, plus raltegravir 1200 mg once daily, for 28 days. The full course should be supplied at the first attendance where possible, because starter packs reduce completion. This matters for Anton, because some people given a starter pack do not return for the rest of the course.
●Raltegravir once daily binds to metal ions. The guideline advises that antacids containing aluminium, magnesium or calcium, multivitamins and iron supplements should ideally be avoided on once daily raltegravir, with a non cation acid reducing agent if needed and non essential supplements stopped. The BNF lists antacids as "avoid" and says to separate oral iron by at least 2 hours. Anton takes a multivitamin with iron and zinc and an occasional antacid, so the prescriber needs to know. Alternative regimens exist where there is an interaction, renal impairment or pregnancy.
●No routine blood monitoring is needed during PEP unless the baseline results are abnormal or there is a clinical reason. PEP is generally well tolerated. Headache, dizziness, nausea and loose stools are the commonly reported effects and are usually mild. Missed doses reduce protection, so advise a regular daily time and a reminder.

Tests: Today and Later

●Baseline for sexual exposure: HIV antigen and antibody test, creatinine with eGFR, alanine transaminase, hepatitis B serology (surface antigen, surface antibody and core antibody) if not known to be immune, syphilis serology, chlamydia and gonorrhoea tests and hepatitis C screening in men who have sex with men. Start PEP without waiting for the results.
●Why a test today does not settle it: it shows his starting position and cannot rule out an infection acquired two nights ago. Anton needs to understand this, because it is the main source of his anxiety.
●Final HIV test: at least 45 days after completing the course, which is about 73 days or 10.5 weeks after exposure if the full 28 days are taken. For sexual exposures it can be done at week 12 to align with syphilis testing. The date should be booked at the treatment visit. Repeat chlamydia, gonorrhoea and syphilis testing after the incubation period.

Hepatitis B, Vaccination and Ongoing Prevention

●Anton has no record of hepatitis B immunity. Hepatitis B serology at baseline guides action. The guideline recommends an ultra rapid hepatitis B vaccination course where there is no immunity and it is clinically indicated. Hepatitis A and human papillomavirus vaccines are offered to men who have sex with men according to the BASHH guidance the guideline cites.
●People with ongoing risk should be moved from PEP to PrEP without a gap, with an HIV test at transition, and encouraged to have regular sexual health checks. Anton has had several partners in two years and condoms are not used every time, so he is a good candidate for a PrEP discussion.
●Present this as an offer, not a lecture. A clinic visit for PEP is the best moment for counselling about safer sex.

Safety Netting and Practical Points

●Condoms for any sex until the final HIV test is clear, as someone who has started PEP is not yet known to be uninfected.
●Seroconversion illness usually appears within a few weeks of infection and can include a flu like illness with fever, sore throat, rash, swollen glands and mouth ulcers. It can be mild. The guideline advises urgent review for a rash or flu like illness during or after PEP, so anyone with these symptoms in the weeks after exposure needs prompt advice, and an HIV test even if the baseline was negative. Severe vomiting that prevents doses, jaundice, or a rash on PEP needs same day review.
●He should keep the tablets in their original packaging and know how to reach a clinician. Give a named contact, such as the issuing clinic, and say what to do if he cannot get advice out of hours, such as using the emergency department or NHS 111.
●Confidentiality: sexual health clinics are confidential. Ask what he is comfortable having in his GP record and who may see it, rather than assuming.
●Offer to check later that he has been seen. This closes the loop on the single riskiest step, which is a patient who is told to attend but does not.

Common Mistakes in This Station

●Ordering an HIV test and a follow up appointment without recognising the 72 hour window.
●Telling him a negative test today means he is clear, or that no test is any use.
●Sending him to a routine appointment, giving a number to ring, booking for tomorrow, or agreeing to wait for the clinic's Monday walk in, which falls after the 72 hour window.
●Delaying treatment while trying to trace the partner or waiting for baseline results.
●Missing the antacid and mineral supplement when taking the medicines history.
●Overlooking hepatitis B immunity, other sexually transmitted infection screening or the follow up HIV test date.
●Giving a lecture on condoms and dating apps before the plan is agreed.
●Safety netting with "come back if you feel unwell" and no named symptoms or out of hours contact.

Mapped to the RCGP curriculum topic: Sexual Health.

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