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. Following an extensive discussion with the physician, the patient agrees to undergo testing for HIV and other sexually transmitted diseases. Polymerase chain reaction testing results indicate that he is positive for HIV. The physician discloses these results to the patient during a follow-up appointment later in the week. After he hears this news, he says, "How could this have happened to me? I only had unprotected sex once or twice. Are you sure those are my test results? I am shocked at this. I mean, I am such a healthy person." The physician supports the patient and educates him about HIV infection and antiretroviral therapy. He explains the importance of consistent and correct condom use and the importance of informing his fiancée. The patient begins to cry and says, "I don't know if I could ever tell her; I am afraid she will leave me." Which of the following is the best next step in responding 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. Following an extensive discussion with the physician, the patient agrees to undergo testing for HIV and other sexually transmitted diseases.  Polymerase chain reaction testing results indicate that he is positive for HIV.  The physician discloses these results to the patient during a follow-up appointment later in the week.  After he hears this news, he says, "How could this have happened to me?  I only had unprotected sex once or twice.  Are you sure those are my test results?  I am shocked at this.  I mean, I am such a healthy person."  The physician supports the patient and educates him about HIV infection and antiretroviral therapy.  He explains the importance of consistent and correct condom use and the importance of informing his fiancée.  The patient begins to cry and says, "I don't know if I could ever tell her; I am afraid she will leave me."  Which of the following is the best next step in responding to this patient?

Quizplus · Accepted Answer

Explanation: Disclosure of HIV status is a challenge for physicians. In general, all physicians are required to report positive HIV test results to the Department of Public Health. However, regulations regarding HIV disclosure to endangered third parties vary depending on location. Some states have laws (such as partner notification and duty to warn) that apply to health care providers, and some states criminalize the withholding of HIV status information. Other states have anonymous partner notification systems through the public health system. This patient has just been told of his diagnosis and is very upset about the thought of disclosing his HIV-positive status to his fiancée. The first step is to try to make an alliance with this patient, with the goal of helping him to disclose his condition himself. (Choice A) This patient is acutely distressed and overwhelmed by his own diagnosis and fears of being abandoned by his fiancée. Although he should be educated about the risks of sexual transmission, this statement is unnecessarily alarming and blaming. (Choice B) Condom use is important in preventing transmission of HIV and must be recommended. However, this statement sends the wrong message that his fiancée does not need to be informed. The patient should be encouraged to tell his fiancée his diagnosis. (Choices C and E) Regardless of local regulations, the physician's first step is always to encourage patients to disclose their HIV status on their own. Educational objective: Disclosure of HIV-positive status to sexual partners is often complicated by fear of rejection. Physicians should support patients by encouraging them to notify their partners as soon as possible. Physicians are not universally required to disclose the HIV status of patients to involved third parties, although all new cases of HIV must be reported to the local Department of Public Health. References: HIV disclosure anxiety: a systematic review and theoretical synthesis. (http://www.ncbi.nlm.nih.gov/pubmed/27406227) Facilitating HIV disclosure across diverse settings: a review. (http://www.ncbi.nlm.nih.gov/pubmed/21493947)

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