Hints and Tips for the Exam

This is a sensitive station. A patient waiting to have a HIV test will be understandably apprehensive and anxious. Part of this anxiety will relate to who will have access to the result of the test and or even know that the patient is having the test. Build a strong rapport early by stating the confidential nature of your discussion with the patient, as well as the fact that you will need their permission before any disclosure (something that is implicit in other OSCE stations). Do not start detailing the finer points of confidentiality with regard to positive results and serious harm unless asked specifically. It is, however, important to mention safe sexual practices while a patient’s status is unknown.

Clarity is key in this station. You will be explaining the testing while also taking a brief history to ascertain the patient’s risk. Asking the patient at regular (and natural) intervals whether they have understood you is important.

Try to use generalised statements and questions to assess the risk of HIV as well as the patient’s level of knowledge. This will make the history more conversational and sound less accusatory. For example:

• ‘Certain risk factors increase a person’s chance of contracting HIV. Are you aware of any?’
  
• ‘That’s right. Also … can increase the likelihood.’
  
• ‘How do you feel about your risk? Would any of these factors apply to you?’

Also ask about the patient’s own perceptions of the disease and be prepared to politely correct any incorrect preconceived notions such as HIV being a disease solely of the homosexual population.

In some medical schools, one hurdle students are expected to navigate relates to the use of terms such as ‘homosexual’. Refrain from using this, and ask directly about whether the patient has ever had sex with a man or whether their partner has (i.e. a man who has sex with another man).

A difficult area of the station is explaining the practicalities of the test, especially the window period. Practise this and have a memorised statement that is short and clear, such as: ‘All HIV tests have a “window period” of 3 months. This means that if a person was exposed to HIV in the previous 3 months, the test may not pick this up, and they should come again for re-testing.’ Note that this means the individual should have two tests separated in time.

Marks will be awarded for assessing the patient’s expectations of the result and how they will cope. Who will they disclose to? Do they have adequate support at home? Would they benefit from seeing a counsellor? You may also mention the Terrence Higgins Trust, which provides support and information regarding HIV and AIDs.

A common difficulty among students is explaining the difference between HIV and AIDS. Make sure you have memorised a clear statement such as:

• ‘HIV is an virus infection that damages the protective cells in the body, weakening the immune system.’ (Note the lack of the word ‘your’)
  
• ‘AIDS is a result of untreated long-standing HIV infection. When the immune system is very weak, the body cannot defend itself against other infections.’
  
• ‘The test detects the HIV virus and not AIDS.’

Results can usually be available with a few minutes for the POCT or up to 2 weeks for the blood test. Results are usually given in person if the patient is deemed high risk. Low-risk patients can be phoned, texted or sent a letter.

The patient can, of course, decline the test (after all your hard work!). Although this is unlikely in the OSCE, be prepared for this and aim to explore their reasons for this and gently persuade of the benefits – but do not try to force them.

The point of the OSCE is to determine first and foremost whether you will be a safe junior doctor. Akin to this is good documentation. Remember to mention to the patient (and the examiner) that you would document everything discussed today.

Potential Variations at This Station

• You may have to talk to a HIV-positive patient who is having unprotected sex and does not wish to disclose to their partner.
  
  
  
  • This variation requires you to assess the risk to the partner of contracting HIV as a result of unsafe sexual practices.
    
  • You will also need to explore the patient’s reasons for not telling their partner, as well as their awareness of the risk of transmission.
    
  • You may be asked what will happen if they refuse to disclose their status to their partner. Here you will have to clearly explain the boundaries of doctor–patient confidentiality.
    
    
    
    • Say particularly that you would have to disclose in the interests of the partner to prevent transmission.
      
    • The patient would be notified prior to disclosure.
      
    • Only as much information as is needed will be disclosed.
      
    • It is worth mentioning that a doctor dealing with such a case should seek advice from their medical defence union on how to deal with it.
    
    
  • Remember to ask at regular intervals if the patient understands.
    
  • Allow them to make a decision in their own time. But remember to advise them to practise safe sex to prevent transmission in the interim.
    
  • If the situation arises where both parties are HIV-positive, this still does not remove the need for protection as they may have different serotypes (HIV-1 and HIV-2). This also increases the risk of resistance to HAART (if partners have different resistant strains) and subsequently makes it more likely that treatment will fail.
  
  
• You may have to counsel a pregnant woman about an HIV antenatal test.
  
  
  
  • Use the phrase ‘routine test’ as this will ease conversation.
    
  • Knowing the mother is HIV-positive will mean:
    
    
    
    • Caesarean section
      
    • Prompt antiretroviral treatment for the baby after delivery
      
    • Advice regarding breast-feeding

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