Cases/Allergy and Immunology

Young Woman Requesting Hiv Test — Free SCA Practice Case

Young woman requesting HIV test

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

Chloe Watson

Age

24 years

Consultation Type

Video

Age

Past Medical History

Generally fit and well.

●No chronic illnesses.

Medication History

●Microgynon 30 (Combined Oral Contraceptive) - States good compliance.
●NKDA.

Recent Medical Notes

●2 Years Ago: Sexual Health Screen (Negative for Chlamydia/Gonorrhoea/HIV).
●Current Situation: Self-booked via app.
●Reason for Encounter: "Requests HIV testing after a recent incident."
●Last BP/BMI: Not recorded in last 3 years.

Patient Script

For the friend playing the patient role

Character Overview: You are Chloe, a junior solicitor at a top-tier firm. You are professional and articulate, but beneath the surface, you are spiraling into a "catastrophic" mindset. You feel a deep sense of shame and are terrified of any professional repercussions.

Opening Sentence: "Hi Doctor, thanks for seeing me. I'm really struggling... I had a bit of a lapse in judgment a couple of nights ago and I'm terrified I've put myself at risk of HIV. I need a test immediately."

A. History if Asked (Data Gathering Phase)

●The Exposure Details: The incident happened 40 hours ago. You were at a work party, drank heavily, and had unprotected vaginal sex with a man you don't really know. You didn't use a condom.
●The Partner: You don't know his name or anything about him. You didn't see any needles or drug use. It was a one-time encounter.
●
The Social Barriers — The Job: You are in line for a promotion to Senior Associate. You are convinced that if "HIV" or "STI" appears on your GP record, your firm's private health insurance or Occupational Health will find out and you will be viewed as "high risk" or "unreliable."
- ●Alcohol: You've been "binge drinking" on Friday nights to cope with 14-hour workdays. This is the first time it has led to a sexual risk, and you are disgusted with yourself.
●Clinical Safety/Symptoms: You have no symptoms (no fever, no rash, no sore throat). You are not on any other meds.

ICE — Ideas, Concerns, Expectations

●
Ideas: You've been Googling obsessively since the incident and have read that HIV can be transmitted through a single unprotected encounter. You don't know much about actual transmission risk statistics — you just know "it only takes once" and that thought has consumed you. You have no reason to believe the man was HIV-positive, but the uncertainty is unbearable.
●
Concerns: Your deepest fear is a career-ending diagnosis. You're terrified that having HIV would destroy the professional reputation you've spent years building. Beyond that, you're ashamed of what happened — you see it as a catastrophic loss of control, completely out of character. You're also worried about what this says about your drinking.
●
Expectations: You want a definitive HIV test today that will tell you you're clear so you can draw a line under it and move on. You want reassurance that this can be handled discreetly without anything appearing on records that could reach your employer. If a test can't give you a definitive answer today, you want to know what the fastest route to certainty is.

If Asked — Medical History and Medications

●Microgynon 30 (Combined Oral Contraceptive): "Yes, I'm on the Pill — Microgynon. I've been on it for about four years, never really had any problems with it. I take it properly, I don't miss pills. I suppose that's partly why I wasn't thinking about a condom — I was thinking about pregnancy, not... this."
●Previous Sexual Health Screen (2 years ago): "I had a full screen done about two years ago when I started seeing my ex. Everything came back clear — Chlamydia, Gonorrhoea, HIV, all negative. I haven't had a test since because I was in a relationship until about six months ago."
●Allergies: "No, no allergies to anything that I know of."
●No other medications: "Just the Pill, nothing else. I don't take anything regularly — not even paracetamol really."

Social History and Lifestyle Impact

●Occupation and daily life context: You qualified as a solicitor two years ago and are currently working in the corporate finance department of a City law firm. You regularly work 12–14 hour days and have been on a major deal that is closing on Monday. Your entire professional identity is built around being competent, controlled, and reliable.
●Lifestyle impact of the condition: Since the incident, you have barely slept. You spent all of Saturday reading about HIV transmission online and have been unable to concentrate on the deal documents you need to review before Monday. You called in sick to a team dinner last night because you couldn't face your colleagues. You are terrified of going into the closing meeting on Monday without knowing your status — "I can't sit across a table from partners and clients pretending everything's fine when I'm falling apart inside." The anxiety is worse than anything you've experienced, and it is compounding the shame you already feel about the drinking.

If Asked — Associated Symptoms

●If asked about vaginal discharge: "No, nothing unusual — everything seems normal down there."
●If asked about dysuria or burning when passing urine: "No, no pain or burning when I go to the loo."
●If asked about lower abdominal or pelvic pain: "No, no pain in my tummy or anything like that."
●If asked about abnormal vaginal bleeding or intermenstrual bleeding: "No, my periods have been regular. No bleeding between periods."
●If asked about sore throat: "No, my throat's fine."
●If asked about mouth ulcers or oral lesions: "No, nothing in my mouth."
●If asked about skin rash: "No, no rashes anywhere."
●If asked about fever, night sweats, or flu-like symptoms: "No, nothing like that. I feel physically fine — it's just mentally I'm a wreck."
●If asked about swollen glands or lymph nodes: "No, I haven't noticed any lumps or swelling."
●If asked about fatigue or weight loss: "I'm exhausted, but that's the stress and not sleeping — it's not like an illness-tired."
●If asked about genital sores or ulcers: "No, nothing like that at all."
●If asked about whether consent was given / whether she felt safe: "Yes — I mean, I was very drunk, but it was... consensual. I just wish I hadn't done it. I made a stupid decision."
●If asked about recreational drug use: "No, just the alcohol. I don't do drugs."
●If asked about previous sexual partners or number of partners: "I've only been with three people including this one. My ex and I were together for two and a half years — he was the last person before this. I'm not someone who does this."
●If asked about whether contraception failed or whether she could be pregnant: "I'm on the Pill and I haven't missed any, so I don't think I'm pregnant. But honestly, I hadn't even thought about that — it's the HIV that's been consuming me."

B. Responses to Management (The Negotiation Phase)

●
If the Doctor suggests a test today:
- ●Reaction: "If it's negative today, can I just move on and forget this happened? I need to know I'm okay before I go back to work on Monday." (This tests if the doctor explains the Window Period).
●
If the Doctor suggests PEP (Post-Exposure Prophylaxis):
- ●Reaction: Fearful. "I've heard those drugs are like chemotherapy. I have a 12-hour closing meeting on Monday. Will I be able to function? Are the side effects worth it if I don't even know if he had anything?"
●
If the Doctor suggests the GUM (Sexual Health) Clinic:
- ●Reaction: Firm refusal. "Absolutely not. The local clinic is two blocks from my office. I cannot risk being seen there by a colleague. You have to handle this here, or I'll just take my chances."
●
If the Doctor mentions Condoms/STIs:
- ●Reaction: "I thought the Pill protected me? I mean, I know about Chlamydia, but you can just take an antibiotic for that, right? It's HIV that scares me."

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 22 indicators checked+0−0

Positive (0/11)

Negative (0/11)

Domain 2: Clinical Management and Medical Complexity

0 / 36 indicators checked+0−0

Positive (0/18)

Negative (0/18)

Domain 3: Relating to Others

0 / 22 indicators checked+0−0

Positive (0/11)

Negative (0/11)

Clinical Learning Points

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.

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.

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.

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).

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.

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.

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.

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.

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.

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.

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.

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.

Mapped to the RCGP curriculum topic: Allergy and Immunology.

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