A 31-year-old man comes to the office for a routine annual examination. The patient mentions that he is engaged to be married, but adds that he is not sure he is ready to make a commitment. He says, "I love my fiancée, but I have recently had some relationships with men. My fiancée wants to have children as soon as we are married, but I feel 'boxed in' by this and want to be absolutely sure that this is what I want." The patient feels conflicted, as he enjoys sex with his fiancée but wonders about other options. He has had sexual intercourse with men in the past and has used condoms most of the time. The patient does not use illicit drugs, except for MDMA occasionally at parties. Examination shows oral thrush and generalized lymphadenopathy. The rest of the physical examination is normal. When the physician recommends that the patient undergo HIV testing, he refuses.
Which of the following would be the most appropriate response to this patient?

Question

A 31-year-old man comes to the office for a routine annual examination.  The patient mentions that he is engaged to be married, but adds that he is not sure he is ready to make a commitment.  He says, "I love my fiancée, but I have recently had some relationships with men.  My fiancée wants to have children as soon as we are married, but I feel 'boxed in' by this and want to be absolutely sure that this is what I want."  The patient feels conflicted, as he enjoys sex with his fiancée but wonders about other options.  He has had sexual intercourse with men in the past and has used condoms most of the time.  The patient does not use illicit drugs, except for MDMA occasionally at parties.  Examination shows oral thrush and generalized lymphadenopathy.  The rest of the physical examination is normal.  When the physician recommends that the patient undergo HIV testing, he refuses.
Which of the following would be the most appropriate response to this patient?

Quizplus · Accepted Answer

Explanation: When faced with a potentially frightening diagnosis, patients will often refuse to comply with further diagnostic testing. This may be compounded by the possibility of a condition such as HIV, which continues to be stigmatized despite effective antiretroviral therapies. Physicians need to recognize this resistance as a sign that the patient has fears and reservations that should be addressed in an empathic and open-ended manner. This patient has a high probability for HIV, as evidenced by oral thrush, lymphadenopathy, and patterns of sexual behavior with ineffective safe-sex methods (inconsistent use of condoms). The first step is to explore the patient's reasons for refusing the test and address his concerns in an effort to gain his consent for HIV testing. Establishing the diagnosis of early HIV infection is a public health concern, as such patients without awareness of their infection will continue to engage in risky activities that place others at risk. (Choice A) This statement may be perceived as judgmental and blaming, and may inhibit this patient from expressing his fears and concerns about HIV testing. (Choice B) Although safe sex methods should be discussed, it would be premature to accept this patient's refusal to be tested without first attempting to explore and address his concerns. (Choice C) This statement attempts to reassure and educate the patient before exploring his concerns. Educating this patient about the prognosis of HIV infection would be more appropriate and may be better received after the physician has elicited the reason that the patient is declining HIV testing. (Choice E) Many states have mandatory reporting to the Department of Public Health for positive HIV status. However, this patient's HIV status has not been confirmed, and the first step is to encourage him to undergo testing. Educational objective: Patients who refuse recommended diagnostic testing may be acting out of fear, anxiety, or denial. The physician's first step is to understand the reasons for refusal and address them in an open-ended, empathic manner. References: HIV prevention in clinical care settings: 2014 recommendations of the International Antiviral Society-USA Panel. (http://www.ncbi.nlm.nih.gov/pubmed/25038358) HIV testing in men who have sex with men: a follow-up review of the qualitative literature since 2010. (http://www.ncbi.nlm.nih.gov/pubmed/28331992)

A 31-Year-Old Man Comes to the Office for a Routine