Young Woman Requesting Hiv Test — Free SCA Practice Case

1. PEPSE — The 72-Hour Window and How to Act

Post-Exposure Prophylaxis after Sexual Exposure (PEPSE) must be offered as soon as possible and no later than 72 hours after the exposure. Every hour of delay reduces efficacy.

• ●Chloe is at 40 hours post-exposure — she is eligible and this is a clinical urgency.
• ●PEPSE is a 28-day course of antiretroviral therapy. The standard BASHH-recommended regimen is Truvada (tenofovir/emtricitabine) plus dolutegravir (or raltegravir as an alternative). The prescribing clinician should confirm the current locally-available regimen.
• ●Common side effects — nausea, diarrhoea, headache, fatigue — are real but usually mild and tend to settle after the first few days. Advise the patient that side effects alone are not a reason to stop the course; stopping early significantly reduces effectiveness.
• ●If the GP surgery cannot prescribe PEPSE immediately, the patient must be directed urgently to A&E or an open sexual health service — whichever can be reached fastest within the remaining window. Document the referral clearly.

2. Risk Stratification — Contextualised, Not Catastrophised

The candidate must provide a proportionate risk assessment based on the actual exposure, not the patient's catastrophic framing.

• ●The estimated HIV transmission risk from a single episode of unprotected vaginal intercourse with a partner of unknown status from the general UK population is approximately 1 in 1,000 (0.1%) per act — substantially lower than anal receptive intercourse.
• ●Key variables that modify risk include: known or suspected HIV status of the source partner, evidence of injecting drug use, country of origin (higher-prevalence regions carry higher risk), and the presence of concurrent genital ulceration (which increases transmission).
• ●In this case, there is no information suggesting elevated source risk — but unknown status is not zero risk, and the offer of PEPSE remains appropriate where within the 72-hour window and the patient consents.
• ●Present this information clearly: it allows Chloe to make an informed decision about PEPSE without either false reassurance or escalation of her existing anxiety spiral.

3. HIV Testing — Window Periods and What Tests Can and Cannot Tell You

Accurate knowledge of the HIV testing window period is essential; getting this wrong is a patient safety issue.

• ●A test today serves as a baseline only — to confirm Chloe's HIV-negative status before the exposure. A negative test today says nothing about whether infection occurred 40 hours ago.
• ●Final HIV testing is recommended at a minimum of 45 days after the PEP course is completed. If the 28 day course is completed, this is a minimum of 73 days (10.5 weeks) after exposure. For sexual exposures this can be performed at 12 weeks to align with syphilis testing.
• ●If PEPSE is taken, it may suppress viral replication and delay seroconversion — so testing should be timed from PEPSE completion, not from the exposure date.
• ●Never imply or state that a negative test today means the patient is clear of this exposure. This is one of the most common and consequential errors in this type of consultation.

4. Baseline Investigations — HIV Is Not the Only Risk

The same exposure that carries HIV risk also carries risk for other sexually transmitted infections. A comprehensive baseline screen is required.

• ●Blood-borne viruses: HIV Ag/Ab (4th-generation), hepatitis B surface antigen and core antibody, hepatitis C antibody.
• ●Bacterial STIs: nucleic acid amplification test (NAAT) for chlamydia and gonorrhoea (vulvovaginal swab or urine); syphilis serology (RPR/TPHA or equivalent).
• ●Some of these infections have shorter window periods than HIV and may require repeat testing if initial screens are negative.
• ●Explaining to the patient that the screen is broader than HIV — and why — is both clinically appropriate and often reassuring (it reframes the consultation as thorough and proactive, rather than alarming).

5. Hepatitis B — Do Not Overlook

Hepatitis B is sexually transmitted and can be prevented by vaccination. This must be considered at this consultation.

• ●Check vaccination history. If Chloe has not been vaccinated (or her status is unknown), offer hepatitis B vaccination now.
• ●An accelerated vaccination schedule (0, 1, and 2 months, with a booster at 12 months) is available in the context of recent exposure and should be offered if she is unvaccinated.
• ●Hepatitis B serology (HBsAg, anti-HBs, anti-HBc) should be included in the baseline blood screen.

6. Emergency Contraception — Confirm Before Closing

Confirm that pregnancy risk has been systematically considered, even when the patient has not raised it.

• ●Chloe takes Microgynon 30 and reports consistent adherence with no missed pills. In this scenario, emergency contraception is not indicated — but this must be confirmed explicitly.
• ●Documenting that contraceptive efficacy was assessed demonstrates systematic clinical thinking and closes a potential gap in care.

7. Confidentiality — What Employers and Insurers Can Actually Access

Many patients have significant and often inaccurate beliefs about who can see their GP records. Providing specific, accurate information is both clinically and therapeutically important here.

• ●Employers have no automatic right of access to GP records. Occupational health assessments are governed by patient consent; a GP record entry about an STI screen does not reach an employer without the patient's explicit authorisation.
• ●Private health insurance: insurers may ask about pre-existing conditions on application, but patients disclose on their own terms. An STI screen in GP records does not trigger automatic insurer notification. Future disclosure obligations depend on specific policy terms and whether a diagnosis is made.
• ●Sexual health records held within a GUM clinic carry additional statutory confidentiality protections under NHS and public health regulations, offering a higher level of privacy than standard GP records.
• ●Correcting Chloe's misconception about record access is not a peripheral task — it directly affects her willingness to engage with care and access appropriate services.

8. GUM Clinic Refusal — Offer an Alternative, Not a Lecture

When a patient refuses the local sexual health clinic, the appropriate response is to explore what would work, not to insist or abandon the referral pathway.

• ●Alternatives to consider: a clinic in a different part of the city, online self-referral to a service in another area, the national sexual health helpline, or GP-initiated management where locally available.
• ●A patient who leaves the consultation without a clear pathway for PEPSE access because the doctor accepted her refusal without offering alternatives represents a management failure.

9. Seroconversion Illness — Safety-Netting Specific to This Case

All patients post-exposure require specific safety-netting about acute HIV seroconversion illness.

• ●Seroconversion illness typically occurs 2–6 weeks after exposure and can include fever, sore throat, rash, swollen lymph nodes, mouth ulcers, and flu-like symptoms.
• ●Advise Chloe that if she develops any combination of these symptoms over the coming weeks, she should seek urgent review and mention this exposure — even if she is taking or has completed PEPSE.
• ●The timeline makes seroconversion illness from this exposure unlikely at 40 hours, but the patient should know what to watch for.

10. Alcohol Use — Brief Intervention, Not a Lecture

The binge-drinking pattern is a clinical issue in its own right and must not be ignored or over-emphasised.

• ●Chloe describes weekly episodes of heavy drinking driven by occupational stress (12–14 hour days). This incident represents the first time it has directly led to a sexual risk.
• ●A proportionate response is to acknowledge the pattern, link it non-judgmentally to the work pressure she has described, and offer brief signposting — for example, Drinkline (0300 123 1110) or her firm's Employee Assistance Programme (EAP) — while being clear that this is not the focus of today's consultation.
• ●Avoid making the alcohol discussion feel like a secondary lecture after an already challenging consultation; frame it as a follow-up item to revisit once the acute situation has resolved.

11. Psychological Support — Recognise the Functional Impairment

Chloe's anxiety is causing significant functional impairment: insomnia, inability to work, social withdrawal. This is clinically significant and should be addressed, not merely acknowledged.

• ●Once a clear management plan is in place, the anxiety often reduces substantially — establishing structure and certainty is itself therapeutic for a patient in a catastrophic thinking spiral.
• ●If anxiety remains significant at follow-up, consider signposting to talking therapy (self-referral to NHS Talking Therapies) or workplace counselling via her EAP.
• ●Document the psychological impact, as this may inform future consultations and continuity of care.

12. Common Candidate Mistakes in This Case

• ●Testing and reassuring without discussing PEPSE: Offering a test and implying the patient just needs to wait is the most serious error — it misses the time-critical intervention and fails the patient at the most important clinical moment.
• ●Implying a negative test today means she is clear: Fundamental misunderstanding of the window period. Candidates must explain that today's test is a baseline, not a result.
• ●Accepting the GUM clinic refusal without offering alternatives: Leaving the patient without an access pathway because she declined one option is a management failure.
• ●Narrowing the investigation to HIV only: The same exposure carries risk for chlamydia, gonorrhoea, syphilis, hepatitis B, and hepatitis C. A full baseline screen is indicated.
• ●Overstating PEP side effects in a way that deters the patient: Side effects are real but manageable; candidates who say "it's like chemotherapy" without qualification may cause the patient to decline treatment she would benefit from.