Breaking Bad News OSCE - HIV Positive Result

Case Overview

• Age/Sex: 19-year-old male
• Occupation: University student, varsity athlete
• Setting: Student health clinic — follow-up visit
• Chief complaint: "I'm here for test results"

Patient Script

Who I Am

I'm a 19-year-old college student who plays on the university rugby team and lives in a shared dorm.

What Brings Me In

I got a call saying one of my tests was positive and I was asked to come back to talk about the results.

My Story

About 6 weeks ago I had a new sexual partner and we sometimes didn't use condoms. Then, about 3 weeks ago I got fever, sore throat, felt very tired, and noticed a spotty red rash on my chest and back that lasted several days. I thought it was just a bad cold or the flu. I went to student health because my sore throat didn't get better quickly; they did some blood tests and said they'd call me if anything needed follow-up. I got a call a few days ago asking me to come in for results.

I also got a flu vaccine from the campus clinic about 2 weeks ago (I had muscle aches and felt off for a day after that), and I tweaked my shoulder lifting weights so I've been taking some over-the-counter ibuprofen. I use protein powder and creatine for training. I used to have glandular fever (mono) in high school.

My Medical Background

• Past medical history: Glandular fever at age 16; no chronic illnesses
• Medications: Occasional ibuprofen; creatine and protein supplements; topical acne wash
• Allergies: None known
• Social: Lives with roommates, non-smoker, drinks alcohol socially (2–4 drinks/week), uses cannabis occasionally; sexually active, mostly male partners, condoms used inconsistently; no injection drug use
• Family history: Parents alive and well, no known hereditary illnesses

What I Think & Worry About

• I think this might be something serious because they sounded urgent when they called.
• I'm worried about what this result means for my health and my sports career — will I have to stop playing?
• I'm scared about telling my parents and partners and about what people will think.
• I hope you can explain what the result means and what I should do next.

If You Ask Me About Other Symptoms...

• Fever: "I had fevers and chills about three weeks ago for several days, then it settled down. I don't have a fever today."
• Cough/breathing: "No cough or shortness of breath — just a scratchy throat for a while."
• Rash: "It was red and spotty on my chest and back, itchy a little, lasted about 4–5 days and then faded."
• Weight/appetite: "I felt off and didn’t feel like eating for a few days but I haven’t lost a lot of weight."
• Lymph nodes: "My neck felt swollen when I pressed it at the time, but that also improved."
• Recent procedures or injections: "No recent tattoos or piercings. I had the campus flu vaccine two weeks ago."
• Partners/sex: "I had a new male partner about 6 weeks ago; we didn’t always use condoms. I’ve had a few partners in the past year."
• Drug use: "I don’t inject drugs. I use cannabis sometimes."
• Travel: "No recent travel abroad."

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Clinical Summary

Examination

• General: Alert, well-looking, athletic young man, not in acute distress
• Vitals: Temperature 36.7°C, HR 92 bpm, BP 118/72 mmHg, RR 14/min, SpO2 99% on air
• HEENT: Pharynx mildly erythematous without exudate
• Lymph nodes: Small, mobile, non-tender cervical and axillary lymphadenopathy palpable (1–2 cm)
• Skin: Faint maculopapular erythematous lesions noted on upper chest and back (resolving)
• Cardiovascular/Respiratory/Abdomen: Normal on brief exam

Investigations

• HIV 4th-generation Ag/Ab assay: Reactive (p24 antigen detected) (interpretation: positive screening result suggesting acute or established infection)
• HIV-1 RNA PCR (viral load): 1,200,000 copies/mL (interpretation: very high viral load consistent with acute/early infection)
• HIV-1/2 antibody IFA or confirmatory assay: Indeterminate/negative (interpretation: seroconversion in early phase; p24 and RNA confirm infection)
• CD4 count: 550 cells/µL (36%) (interpretation: within low-normal range for early infection)
• Full blood count: WBC 4.1 x10^9/L, lymphocytes 1.1 x10^9/L (mild relative lymphopenia)
• LFTs: ALT 58 U/L (mildly elevated), AST 46 U/L
• Syphilis serology (RPR): Non-reactive
• Hepatitis B surface antigen/antibody: HBsAg negative, anti-HBs pending
• Hepatitis C antibody: Negative

Diagnosis

• Primary diagnosis: Acute HIV infection (recent seroconversion) — supported by compatible history (fever, sore throat, rash ~3 weeks after exposure), reactive 4th-gen test with p24 antigen positive, and very high plasma HIV-1 RNA confirming acute infection.

• Key differentials:

  • Infectious mononucleosis (EBV/CMV): similar presentation of fever, sore throat, lymphadenopathy; serology would help exclude — patient reports prior mono in adolescence and current EBV serology would distinguish.
  • Acute viral pharyngitis/influenza: less likely given positive HIV tests and high viral load; recent flu vaccine is a red herring.
  • Early acute hepatitis B: can present with systemic symptoms and transaminase elevation but hepatitis B serology is negative.

Management

• Immediate counseling: Inform patient of diagnosis in a sensitive, private manner; assess understanding and provide emotional support.
• Confirmatory and baseline tests already ordered/obtained: HIV-1 RNA (done), CD4 count, baseline renal function, LFTs, Hep B/Hep C serologies, STI screen, and pregnancy not applicable.
• Start antiretroviral therapy (ART) as soon as possible — offer same-day initiation with an integrase inhibitor–based regimen after baseline labs and resistance testing are sent.
• Send baseline genotypic resistance testing prior to/during initiation of ART to guide regimen.
• Public health actions: Discuss partner notification and expedited partner services; offer testing to recent sexual partners; discuss safe sex and recommend abstaining or using condoms until viral suppression is documented.
• Provide immediate practical advice: avoid blood/organ donation, avoid sharing razors/needles, discuss sports participation per team/institutional policies and standard precautions (routine sports typically allowed)
• Vaccinations and prophylaxis: check hepatitis B immunity; vaccinate if non-immune; consider other routine immunizations as indicated.
• Arrange follow-up: prompt outpatient HIV clinic referral within days, repeat viral load and CD4 at 2–4 weeks after ART initiation, mental health support and social work for disclosure support.

Key Learning Points

• Acute HIV infection often presents 2–4 weeks after exposure with fever, sore throat, lymphadenopathy, and a maculopapular rash; a high plasma viral load and positive p24 antigen with absent/indeterminate antibodies indicate early seroconversion.
• Fourth-generation HIV tests detect p24 antigen earlier than antibody-only tests, but HIV-1 RNA PCR is the definitive test in acute infection and should be used to confirm when acute infection is suspected.
• Rapid linkage to care and prompt initiation of ART (after baseline testing including resistance testing) reduce viral set point, improve outcomes, and decrease onward transmission; psychosocial support and partner notification are essential components of management.