ID · Full case

HIV — primary-care role

BHIVA 2020 NICE CKS
H
HIV · Clinical Reasoning Framework v2
GP & SCA · NICE NG60 / BHIVA 2022 / CKS 2024
CD4 <200AIDS-defining threshold (cells/µL)
<50 copiesUndetectable VL target (copies/mL)
72 hoursPEP initiation window
45 days4th gen test window period (99.9% sensitive)
28 daysPEP course duration
2 weeksStart ART if CD4 <50 (prioritise)
U=UUndetectable = Untransmittable (VL <200)
1 in 8People with HIV unaware of status in UK
📋 Clinical Stem — HIV: Exposure, Diagnosis & Long-Term Management
A patient presents with concern about possible HIV exposure, new HIV diagnosis, or for ongoing HIV management in primary care.
“Ms Fatima Osei, 34, a secondary school teacher, contacts the practice urgently via eConsult: ‘I found out yesterday that someone I slept with three weeks ago may have HIV. I have not been able to sleep. I am terrified and do not know what to do. I have been reading things online all night. Please can I speak to a doctor today.’ She has no significant past medical history recorded.”
This stem covers the full HIV clinical pathway: post-exposure risk assessment, acute seroconversion illness, new diagnosis counselling, and long-term primary care management. Psychosocial complexity — stigma, partner notification, employment implications — is central to all scenarios. BHIVA 2022 recommends ART initiation at any CD4 count, as soon as possible after diagnosis.
Scenario A — Post-Exposure Risk Assessment Recent unprotected sexual contact with a partner of unknown or positive status. No symptoms yet. PEP window may still be open. Needs testing timeline, risk stratification, and follow-up plan.
Scenario B — Acute Seroconversion Illness Patient presents 2–4 weeks after exposure with flu-like illness: fever, pharyngitis, diffuse lymphadenopathy, maculopapular rash. HIV combo test positive. Viral load very high, highly infectious window.
Scenario C — New HIV Diagnosis (Incidental) HIV detected on antenatal screen, pre-op bloods, or at sexual health clinic. Patient is asymptomatic. CD4 count unknown. Needs careful disclosure, counselling, and specialist referral.
Scenario D — Advanced HIV / AIDS Presentation Weight loss, night sweats, oral candida, persistent lymphadenopathy. CD4 unknown. Possible AIDS-defining illness. Needs urgent investigation, same-day hospital referral if OI suspected.
Scenario E — Stable HIV in Primary Care (Monitoring) Known HIV on ART, stable viral load, CD4 well above 350. Attending for annual review, co-morbidity management, drug interactions, or psychosocial wellbeing check.
Key variables to adapt for Route of exposure (sexual/IVDU/needlestick), CD4 count at diagnosis, viral load trajectory, relationship disclosure status, pregnancy, co-infections (HBV/HCV/TB), mental health co-morbidity, immigration status, substance use, and occupational concerns.
Steps:
1
Step 1
History Taking — Open Question First · Targeted Questions · ICE · Psychosocial Context
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HIV history must balance clinical precision with exceptional sensitivity. Patients carrying HIV concerns carry enormous psychological burden. The history serves two purposes: gathering exposure details for clinical risk stratification, and creating a therapeutic alliance that enables disclosure of the full social context. Always open broadly before narrowing to exposure questions. ICE must include the hidden agenda — commonly fear of partner finding out, fear of dying, or fear of discrimination.
🎓 Consultation opener — use existing information first
“I can see from your eConsult that something has happened that has really been worrying you — thank you for reaching out. I want to make sure I understand exactly what is going on. Can you tell me, in your own words, what has been happening?”
References existing information without re-asking what the patient already wrote. The opener validates emotional distress before moving to clinical questions. Asking “What can I do for you today?” when you can see the eConsult loses marks for not using available data.
1A — Open question first, then targeted questions
Question to askWhy it matters clinicallyChanges what?
🟢 OPEN QUESTION — always start here“Tell me what has happened — I am listening, and I want to understand everything that is worrying you.” Allows disclosure of exposure details, emotional state, and hidden agenda simultaneously. Patients often volunteer the key psychosocial complexity spontaneously when given space.SCA: scores Global Skills (listening), Relating to Others (ideas/concerns from outset). DDxPsychosocial
When did this happen?“How long ago was the exposure you are concerned about?” Critical for PEP eligibility: PEP must start within 72 hours. If 45 days+ ago, 4th gen test is now interpretable. If 3–45 days, a window period exists and re-testing at 45 days is needed.Directly determines clinical pathway: PEP vs immediate test vs watch-and-wait. PEP urgentTimeline
What was the nature of the exposure?“Can you tell me more about what happened — what type of contact was it?” Receptive anal intercourse carries highest transmission risk (~1.4% per act without ART). Insertive vaginal ~0.08%. Risk stratification determines PEP urgency.Use gender-neutral language until orientation is established. Never assume. PEP riskRisk strat
Source HIV status and treatment?“Do you know if the person has HIV — and if so, are they on treatment?” Source on suppressive ART (undetectable VL) means transmission risk is negligible (U=U). Confirmed HIV+ source on high VL = strong PEP indication.BHIVA PEP guidelines use a risk matrix: source status x route x time elapsed. PEP decision
Symptoms since exposure?“Have you felt unwell — any fevers, rash, swollen glands, or sore throat?” Acute seroconversion illness 2–4 weeks post-exposure: fever, pharyngitis, maculopapular rash, lymphadenopathy. Viral load extremely high during this phase — highest infectivity.Seroconversion: diagnose urgently with combo test + HIV RNA. Do not dismiss as viral illness. SeroconversionAHI
Previous HIV tests?“Have you ever been tested for HIV before — and when was your last test?” Establishes baseline. Previous negative test limits window period interpretation. Never tested = first test anxiety, needs more counselling preparation.NICE NG60: universal HIV testing in areas with >2/1000 diagnosed prevalence. Testing
Current medications including contraception?“Are you taking anything regularly — including contraception, prescribed medicines, or supplements?” PrEP use is essential to establish — completely changes risk assessment. ART interactions: rifampicin, St John's wort reduce ART levels. OCP efficacy reduced by enzyme inducers (efavirenz).PrEP taken correctly confers >99% protection. Drug interaction
Other STI symptoms?“Any discharge, ulcers, or pain when passing urine?” STI co-infections (syphilis, gonorrhoea, HSV) increase HIV transmission risk by disrupting mucosal barriers. Co-testing for STIs is essential with every HIV test.Full STI screen is mandatory with any HIV test. STI screen
Pregnancy or planning pregnancy?“Is there any chance you could be pregnant, or are you planning a pregnancy?” Maternal HIV must be diagnosed and treated to prevent vertical transmission (PMTCT reduces risk from 25% to <0.5%). ART choice differs in pregnancy — DTG now preferred over EFV.UK Antenatal HIV testing is opt-out. HIV-positive pregnant women need immediate referral. PMTCT
Intravenous drug use or needlestick?“Have you ever injected drugs, or had a needlestick at work?” IVDU with shared equipment is a high-risk route. Healthcare workers: occupational PEP protocol, mandatory incident reporting. IVDU also increases hepatitis B/C co-infection risk.Non-judgemental framing increases honest disclosure. RouteHarm reduction
Alcohol and recreational drugs?“Do you use recreational drugs — and were you using anything on the occasion you are worried about?” Chemsex drugs (mephedrone, GHB, crystal meth) are strongly associated with prolonged unprotected sex, multiple partners, and HIV acquisition in MSM. Affects ART adherence and drug interactions.“Chemsex” should be asked about directly in MSM presenting with HIV concerns — BASHH guidance. Chemsex
1B — Red flags: must not miss · must ask · must act
🚨

Red Flags — act before continuing history

Red flagWhy dangerousAction
Dry cough + progressive dyspnoea + hypoxia (SpO₂ <94%)PCP (Pneumocystis pneumonia) — most common AIDS-defining illness in UK. CD4 typically <200. Mortality without treatment 20–40%. Bilateral ground-glass on CXR. Rapid deterioration possible.999 / A&E
Severe headache + neck stiffness + photophobia + feverCryptococcal meningitis — occurs with CD4 <100. Subacute onset over days–weeks. CSF opening pressure elevated. Mortality 10–30% even with treatment.999 / A&E
New focal neurology / seizures / altered consciousnessCNS toxoplasmosis (ring-enhancing lesions on MRI), CNS lymphoma, or HIV encephalopathy. CD4 typically <100–200. Urgent neurology + HIV specialist.999 / A&E
Visual changes + floaters + decreased acuity (known CD4 <100)CMV retinitis — painless, progressive retinal necrosis. Most common cause of blindness in advanced HIV. Requires urgent ophthalmology + IV ganciclovir. Permanent vision loss if delayed.Same-day ophthalmology
Weight loss >10% + drenching night sweats + fever >1 monthAIDS-defining constitutional syndrome. DDx includes disseminated MAC, lymphoma, or disseminated TB. CD4 typically <50–100. Immediate investigation and HIV specialist required.Same-day
Dysphagia + severe oral candidaOesophageal candidiasis is AIDS-defining (CD4 <200). Inability to eat, weight loss, dehydration. Fluconazole + urgent HIV specialist.Same-day
Active suicidal ideation following new HIV diagnosisHIV diagnosis is a psychological crisis. Suicide risk 2–7 times higher in PLHIV. Acute stress reaction requires immediate risk assessment. Do not leave patient without support.999 or Crisis team
🛡️

Safeguarding Considerations — Consider in Every Consultation

HIV acquisition can be a marker of coercion, exploitation, or abuse. In adolescents, new HIV infection may indicate sexual exploitation or trafficking. In women, inability to insist on condom use is a recognised form of intimate partner violence. Never assume HIV is simply the result of personal choice — always explore the context of how exposure occurred.
🏠 Domestic Abuse / Intimate Partner Violence
  • Inability to negotiate condom use is a recognised form of reproductive coercion
  • Partner may have withheld HIV status or controlled sexual health testing
  • HIV diagnosis may trigger increased abuse if partner fears disclosure
  • Ask: “Are you able to speak freely today? Are there any pressures around your sexual health decisions?”
  • Safety-plan before partner notification if coercive control is suspected
👴 Older Adults / Carer-Related Concern
  • HIV in older adults (60+) is often undiagnosed — clinicians assume low risk
  • Late diagnosis common: CD4 often very low at presentation in older patients
  • Cognitive impairment may impair capacity to consent to sexual activity
  • Care home residents may have sexual activity not discussed with clinicians
  • Consider adult safeguarding referral if consent capacity is uncertain
🧒 Children / Child Sexual Exploitation
  • HIV in adolescents <16 may indicate sexual abuse or exploitation
  • Any sexually active child <13 is a safeguarding concern regardless of context
  • Human trafficking: HIV is common in trafficked individuals
  • Consider whether children in the household are at risk
  • Refer to MASH/children's services if exploitation suspected
💊 Self-Harm / Mental Health Crisis
  • HIV diagnosis can precipitate acute mental health crisis, including suicidality
  • Fear of disclosure may prevent help-seeking and delay treatment
  • Chemsex context: safeguarding concerns around vulnerability and consent
  • HIV criminalisation anxiety: some patients fear legal consequences of disclosure
  • Assess suicide risk at every new diagnosis consultation — use direct questioning
If a safeguarding concern is identified: Document factually in clinical record. Contact named safeguarding lead. For children, Section 47 referral may be indicated. For adults, use local adult safeguarding pathway. HIV confidentiality obligations do not override safeguarding duty.
1C — PMH · FH · Drug history · Social history: management impact
🧬 PMH / FH — changes management
FactorWhy it mattersManagement impact
Hepatitis B (HBV) co-infectionHBV-active drugs (TDF, TAF, 3TC/FTC) must be in ART regimen to prevent HBV flare on stopping.Must use TDF or TAF-containing regimen — never switch off without specialist
Hepatitis C (HCV) co-infectionHCV accelerates liver fibrosis in HIV. DAAs curative in 12 weeks but drug interactions with some ARTs.Refer to hepatology for DAA treatment; check ART–DAA interactions
Active or latent TBTB/HIV most common cause of death in PLHIV globally. Rifampicin interactions require ART regimen change.Delay ART 2 weeks into TB treatment (if CD4 >100); double-dose DTG or use RAL
Chronic kidney diseaseTDF nephrotoxic — causes proximal tubular dysfunction, reduced eGFR. eGFR must be checked before TDF.Switch TDF→TAF if eGFR <70 ml/min/1.73m²
Osteoporosis / osteopeniaHIV reduces bone density; TDF causes additional ~3% BMD loss in first year. FRAX scoring recommended.TAF preferred; DEXA scan; calcium + vitamin D supplementation
Cardiovascular disease / high CV riskHIV independently doubles CV risk. Abacavir (ABC) associated with increased MI risk (D:A:D study).Avoid abacavir if Framingham >20%; monitor lipids; statin interactions with PIs
Psychiatric historyEfavirenz causes CNS side effects (vivid dreams, depression, suicidal ideation) in up to 50%.Avoid efavirenz and monitor DTG; use bictegravir or rilpivirine instead
Abacavir hypersensitivity (HLA-B*5701)HLA-B*5701 allele predicts severe potentially fatal hypersensitivity to ABC. Screen before prescribing.Positive result = absolute lifetime contraindication to abacavir
💊 Drug history · Social history — clinical impact
FactorWhy it mattersManagement impact
Current antiretroviral therapyEstablishes current regimen, adherence, resistance history, and prior virological failures.Resistance genotyping before changing regimen; never stop all ARTs simultaneously
Contraceptive pill / hormonal contraceptionEnzyme-inducing ARTs (efavirenz) reduce OCP efficacy by up to 50%. PPIs reduce rilpivirine levels 40%.Use condoms or alternative contraception with enzyme inducers; avoid PPIs with RPV
St John's Wort / herbal supplementsStrong CYP3A4 inducer — significantly reduces ART levels, especially PIs and NNRTIs. Precipitates virological failure.Absolutely contraindicated with all ARTs; document discussion
Methadone / opioid substitutionEfavirenz reduces methadone levels by 50–60% — can precipitate acute withdrawal.Prefer INSTI-based regimens in IVDU patients on methadone
Recreational drugs / chemsexCrystal meth interacts with ritonavir (cardiac arrhythmia risk). GHB + ART = additive CNS depression. Affects adherence.Avoid ritonavir in crystal meth users; chemsex support services referral
Occupation (healthcare worker)Occupational HIV exposure triggers mandatory PEP via occupational health. EPPs require UKAP regulatory approval.Follow OH PEP protocol; BHIVA/EAGA guidance — undetectable VL allows most EPPs
Immigration / asylum statusSome countries of origin have very high HIV prevalence. Immigration status may affect ART entitlement.ART is free regardless of immigration status; refer to NAT, THT for advocacy
Mental health / psychological wellbeingDepression affects 30–40% of PLHIV. Poor mental health is strongest predictor of poor ART adherence.NHS Talking Therapies referral; PHQ-9 at every review; review ART if EFV or DTG contributing
1D — ICE: Ideas · Concerns · Expectations
💡 Why ICE matters in HIV — not a tick-box exercise

A patient's internal model of HIV is almost always rooted in outdated information (HIV = death sentence, HIV = “deserved consequence”). Concerns are frequently dominated by stigma and relationship consequences rather than medical fear. Failing to elicit ICE in an HIV consultation means providing medically correct but psychologically useless information — the patient leaves more afraid than when they arrived. ICE also reveals the hidden agenda (partner affairs, shame, occupational concerns) that determines what management is actually needed.

💭 Ideas
“Before I go any further — what do you know about HIV? What do you think it means if someone has it these days?”
Reveals the patient's mental model — often “HIV = AIDS = death” based on 1980s imagery. Correcting this outdated belief early (normal life expectancy on ART; U=U) transforms the consultation from crisis to problem-solvable situation.
😟 Concerns
“What is your biggest worry right now — what is the thing that is keeping you up at night? Sometimes it is not just the medical side of things.”
The medical concern (do I have HIV?) is rarely the deepest concern. Common hidden concerns: Will my partner leave me? Will I lose my job? Will my family find out? Will the GP tell anyone? Naming the real concern is more therapeutically powerful than explaining CD4 counts.
🎯 Expectations
“What were you hoping to get from today's appointment — what outcome would make you feel like this had been worthwhile?”
Expectations in HIV consultations are often specific: “I want to know if I need PEP today,” “I want to know if HIV means I will die young.” Eliciting this allows the clinician to meet the expectation explicitly and negotiate where it is medically unrealistic.
1E — Psychosocial context: the person behind the HIV risk or diagnosis
🪶 Social context is not background noise in HIV — it is the pathology

HIV disproportionately affects people living with social adversity: poverty, unstable housing, substance dependence, minority stress, and migration. These are the upstream determinants of HIV acquisition, late diagnosis, and poor treatment adherence. Asking about psychosocial context in an HIV consultation is not a counselling indulgence — it is the clinical skill that determines whether this patient will start and maintain ART, disclose to partners, and attend follow-up.

😕 Stigma and Fear of Testing

HIV-related stigma remains the leading driver of late presentation in the UK. Patients delay testing for months or years due to fear of a positive result becoming known to family, employers, or communities.

“If you did test positive, what would be your biggest worry about who might find out?”

Management change: Address confidentiality explicitly; connect with peer support (THT, Positively UK, GMFA).

💊 Substance Use and Chemsex

Injecting drug use (shared needles) remains a key HIV transmission route. Chemsex (crystal meth, GHB, mephedrone) during sex sessions massively amplifies transmission risk and impairs consent. Substance use directly affects ART adherence.

“Are drugs or alcohol part of your sexual life at all? I ask everyone, because it changes how I can help.”

Management change: Harm reduction; avoid EFV and ritonavir in chemsex; long-acting injectable ART may suit better for chaotic lifestyles.

😫 Mental Health and Psychological Wellbeing

Depression and anxiety are 3–4 times more prevalent in PLHIV. This predates diagnosis (minority stress) and persists after (grief, identity adjustment). Poor mental health is the most powerful predictor of treatment failure.

“How has your mood been — not just about this, but generally over the last few weeks and months?”

Management change: NHS Talking Therapies referral; avoid EFV in active depression; monitor for suicidality especially at new diagnosis.

🏠 Housing, Poverty and Social Instability

Homelessness and poverty independently predict late HIV diagnosis and poor ART adherence. People in unstable accommodation cannot keep medications safely, attend appointments reliably, or store test kits.

“Are you in a stable situation at home at the moment — do you have a secure place to stay?”

Management change: Social prescribing; once-daily single-tablet regimens for chaotic lifestyles; community pharmacy dispensing.

💑 Relationships, Coercion and Partner Dynamics

In some relationships, HIV exposure results from inability to negotiate safer sex — coercive control, fear of violence, financial dependence, or power imbalance. This is especially prevalent in women and young MSM.

“Are you in a relationship? Are you able to make decisions about safer sex freely in your relationship?”

Management change: Domestic abuse pathway if coercion identified; safety-plan before partner notification; PrEP regardless of partner negotiation.

🌍 Migration, Culture and Community Context

Sub-Saharan African communities in the UK have very high HIV prevalence but lower testing uptake due to cultural stigma and fear of deportation. Immigration status may affect NHS entitlement to ART.

“Different communities have different feelings about HIV — is that something you have thought about in terms of people around you finding out?”

Management change: Cultural competence in counselling; clarify NHS entitlement (ART is free regardless of immigration status); interpreter services.

🎓 SCA Checkpoint — Step 1TasksRelating to OthersGlobal Skills
Key phrases that score
“I want to make sure I understand everything that is worrying you — not just the medical side.”
“What do you understand about HIV — what does it mean to you if someone has it these days?”
“What is your biggest fear right now? Sometimes it is not the thing people expect.”
“Everything you tell me today stays completely confidential — with one specific exception I should explain.”
Deductions (examiner flags)
  • Asking “What brings you in today?” when exposure was already in the eConsult
  • Using judgmental language about number of sexual partners
  • Jumping to test ordering before understanding exposure timing
  • Using the word “promiscuous” or implying lifestyle blame
  • Discussing U=U before eliciting patient's ideas about HIV
  • Missing the safeguarding angle in young patients
🔴 Red — failing
No open question. Jumps straight to “when did you last have sex?”. Misses ICE entirely. Does not acknowledge emotional distress. No human connection.
🟠 Amber — borderline
Opens reasonably but ICE rushed or only partially explored. Exposure history gathered but window period implications not explained. Moves too quickly to investigations.
🟢 Green — passing
Open question first. All three ICE domains named and addressed. Exposure timing established and clinical implication explained. Stigma and relationship concerns validated. Confidentiality addressed proactively.
2
Step 2
Triage Engine — Emergency · Urgent · Routine
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HIV triage is a spectrum from asymptomatic monitoring to life-threatening opportunistic infection. The triage decision hinges on two questions: (1) Is there a clinical indicator of severe immunosuppression (CD4 <200 or features of AIDS-defining illness)? (2) Is there a time-critical treatment window (PEP within 72 hours; ART initiation within 2 weeks for CD4 <50)? Most HIV-related primary care presentations are urgent, not emergency — but PCP and cryptococcal meningitis carry high mortality and must be rapidly identified.
🔴 Emergency

999 or A&E Now

Call 999 / A&E immediate
  • Suspected PCPHypoxia (SpO₂ <94%), dry cough, dyspnoea on exertion. CD4 <200 or unknown. CXR: bilateral ground-glass. 999 + inform HIV team.
  • Cryptococcal meningitisHeadache + neck stiffness + fever + photophobia. CD4 <100. LP urgently needed.
  • Focal neurology / new seizuresCNS toxoplasmosis or lymphoma. Ring-enhancing lesions on MRI. CD4 <100–200.
  • CMV retinitis symptomsFloaters, visual field defect, decreased acuity in known HIV (CD4 <100). Same-day ophthalmology.
  • Acute suicidal crisis (new diagnosis)Active suicidal ideation. Do not leave unaccompanied. Crisis team or 999 if immediate risk.
  • Severe wasting + sepsis featuresDisseminated MAC, disseminated TB, or severe bacterial infection requiring IV therapy.
🟠 Urgent

Same-Day or 48-Hour

Same-day / days
  • PEP request within 72 hoursAny high-risk exposure within 72h. Prescribe today or refer to GUM/A&E if out of hours. Every hour matters.
  • New HIV diagnosis (any)Same-day or next-day contact with HIV specialist/GUM. GP: blood tests, safety-net, referral.
  • Known HIV, CD4 <200, not on ARTUrgently restart ART. OI prophylaxis (cotrimoxazole). Refer HIV specialist within days.
  • Acute seroconversion illnessFever, rash, pharyngitis, lymphadenopathy 2–4 weeks post-exposure. Very high VL — highly infectious.
  • Virological failure on ART (VL >200)Resistance concern. Genotyping urgently. HIV specialist within days.
🟢 Routine

Manage in Primary Care

GP / sexual health / HIV clinic
  • Stable HIV on ART, VL undetectableAnnual primary care review. CV risk, smoking, renal function, vaccination, mental health.
  • HIV testing (no acute exposure)Asymptomatic, HIV test requested. Standard 4th gen Ag/Ab test. Post-test counselling planned.
  • PrEP counselling / initiationPrEP assessment, risk counselling, initiation of TDF/FTC or TAF/FTC, baseline renal and STI testing.
  • Partner notification supportIndex patient on ART, virologically suppressed, wanting help facilitating partner testing.
  • ART prescription renewal / monitoringStable patient, shared care, issuing repeat prescriptions with appropriate monitoring.
🎓 SCA Checkpoint — Step 2TasksGlobal Skills
Triage reasoning phrases
“Because it has been three weeks, PEP is no longer an option — but we can do a test today and plan from there.”
“If you develop a severe headache, a stiff neck, or difficulty breathing, go to A&E immediately — do not wait for an appointment.”
Deductions
  • Failing to calculate whether PEP is still within the 72-hour window
  • Not providing OI safety-netting to a new diagnosis
  • Missing that CD4 <50 requires ART within 2 weeks not “when convenient”
🔴 Red
No triage reasoning. PEP eligibility not considered. Sends new diagnosis home without safety-netting.
🟠 Amber
PEP window calculated but implications not explained. OI safety-netting vague.
🟢 Green
PEP eligibility explicitly calculated and explained. Specific OI red-flag symptoms named. Follow-up pathway clear.
3
Step 3
Do I Need This Examination?
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Physical examination in HIV must be CD4-stratified and symptom-directed. In a patient with a post-exposure risk assessment and no symptoms, examination adds little. In a patient with advanced HIV or unknown CD4, systematic examination reveals AIDS-defining signs (oral candida, Kaposi's sarcoma, lymphadenopathy, wasting) that immediately change management. Always examine the oropharynx — oral candida is the most accessible early marker of immunosuppression.
ExaminationWhy it mattersFinding that changes managementChanges management?
Weight and BMIWasting (>10% body weight loss) is AIDS-defining. BMI <18.5 = significant immunosuppression, high OI risk.Baseline essential for monitoring ART metabolic effects (weight gain with DTG/TAF).Weight loss >10% → same-day HIV specialist; BMI <18 → nutritional supportYES — AIDS staging
Observations including SpO₂Fever in known HIV with low CD4 is OI until proven otherwise. Hypoxia (SpO₂ <94%) with normal CXR = classic early PCP.Document SpO₂ at every presentation with respiratory symptoms.SpO₂ <94% → A&E. Fever + CD4 <100 → same-day specialistYES — triage
OropharynxWhite plaques that scrape off = oral candida (CD4 typically <200). White plaques not scraping = oral hairy leukoplakia (EBV-driven, specific to HIV). Oral KS: purple/brown vascular lesions on palate.Oral candida in a patient not on ART should trigger urgent CD4 testing.Oral candida → urgent CD4/VL; fluconazole; HIV specialist. KS → immediate referralYES — immunosuppression marker
Lymph node examinationPGL (nodes >1 cm in ≥2 extra-inguinal sites for >3 months) = common, benign in HIV. Asymmetric, rapidly growing, hard nodes suggest lymphoma or TB lymphadenitis.During acute seroconversion: diffuse soft lymphadenopathy + fever = key finding.Hard/asymmetric/enlarging → urgent biopsy. Generalised soft → monitorContext dependent
Skin examination (head to toe)KS (purplish-brown papules) = AIDS-defining. Maculopapular rash = acute seroconversion. Molluscum contagiosum (large/profuse) = CD4 <100. Abacavir hypersensitivity rash.Examine all skin surfaces — KS can be hidden on soles of feet.KS → immediate specialist. Abacavir HSR rash → STOP abacavir immediatelyYES — AIDS staging / safety
Neurological examinationHAND (HIV-associated neurocognitive disorder): subtle cognitive changes, peripheral neuropathy (burning feet). Focal neurology = OI until proven otherwise.Peripheral neuropathy may be HIV-related or d4T/ddI-related (legacy ARTs).Focal signs → A&E for MRI. Peripheral neuropathy → switch ART; B12; analgesiaYES — emergency vs chronic
Fundoscopy (when CD4 <100)CMV retinitis = “pizza fundus” — haemorrhages and exudates along vessels. Painless. Requires same-day ophthalmology + IV ganciclovir. Permanent vision loss if delayed.Mandatory in any patient with CD4 <100 and visual symptoms.CMV retinitis → same-day ophthalmology. Normal → OI prophylaxis discussionYES — vision-saving
Genital / STI examinationSyphilis chancres or secondary rash may be present. Genital warts (HPV) more extensive in HIV. Penile/vulval/anal cancer risk elevated in PLHIV.GUM specialist examination preferred for full STI screen.Syphilis signs → same-day GUM; benzylpenicillin IM. Active STI → partner notificationContext dependent
🎓 SCA Checkpoint — Step 3TasksGlobal Skills
Examination communication
“I would like to check a few things — particularly your weight, look inside your mouth, and feel your glands. If your immune system has been affected, there can be clues in these areas.”
Deductions
  • Not examining the oropharynx in a symptomatic or advanced HIV patient
  • Failing to document SpO₂ in a patient with cough and dyspnoea
  • Missing skin examination in a first HIV presentation
🔴 Red
Examination completely skipped in symptomatic patient. No mention of vital signs.
🟠 Amber
Basic obs but no targeted HIV examination. Oral cavity not examined.
🟢 Green
Systematic and CD4-stratified examination plan. Oropharynx, skin, lymph nodes, neurological all considered with rationale.
4
Step 4
Do I Need This Investigation?
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HIV investigations serve four purposes: diagnosis, staging, co-infection screening, and treatment monitoring. The 4th generation HIV Ag/Ab combination test is the current diagnostic standard — it detects both HIV antigen (p24) and antibody, becoming positive at a median of 18 days post-infection. HIV RNA becomes detectable before the combo test (10–14 days) and is used when acute HIV infection is strongly suspected with a negative combo test. Co-infection screening (HBV, HCV, syphilis, TB) is mandatory at all new diagnoses.
InvestigationClinical question it answersWhat result changes management?
HIV 4th gen Ag/Ab combination testStandard diagnostic test. Detects p24 antigen (positive from ~18 days) AND HIV antibody (positive from ~25 days). Sensitivity >99.9% at 45 days. Specificity >99.5%.Positive → confirm with HIV RNA + CD4 immediately. Equivocal → repeat at 45 days. Negative within window → retest at 45 days post-exposure.
HIV RNA viral load (VL)Detects HIV genetic material directly — positive 10–14 days post-infection, before combo test. Used in acute seroconversion suspicion with negative Ag/Ab. Primary treatment monitoring tool.VL >1000 in context of exposure → acute HIV infection. VL <200 on ART = undetectable (U=U). Detectable VL on ART → adherence/resistance assessment.
CD4 count and CD4%Absolute CD4+ T-cell count: normal 500–1500 cells/µL. Determines OI risk thresholds and ART urgency.CD4 <200 → start cotrimoxazole prophylaxis NOW. CD4 <50 → ART within 2 weeks + specialist today. CD4 >350 + suppressed VL = stable.
HLA-B*5701 genotypeScreens for allele predicting severe, potentially fatal hypersensitivity to abacavir (ABC). ~6% European, ~3% Black African ancestry.Positive → absolute lifetime contraindication to abacavir. Negative → abacavir safe to use with counselling.
Hepatitis B (HBsAg + core Ab + surface Ab)HBV/HIV co-infection: 10% of UK HIV patients. Active HBV requires TDF or TAF in ART regimen. Stopping these drugs causes potentially severe HBV flare.HBsAg positive → MUST include TDF or TAF. HBV-naïve → vaccinate (3-dose; accelerated if starting ART soon).
Hepatitis C antibody ± HCV RNAHCV co-infection accelerates hepatic fibrosis. HCV cure with DAAs achievable in 12 weeks but drug interactions require specialist planning.HCV Ab positive → HCV RNA to confirm active infection → hepatology/GI referral. Negative → screen annually if ongoing risk.
Syphilis serology (TPHA/VDRL)Syphilis at record high in UK, particularly in MSM and PLHIV. Syphilis and HIV are synergistic. Neurosyphilis more common and severe in HIV.Syphilis positive → benzylpenicillin IM; assess for neurosyphilis if CD4 <350. Partner notification mandatory.
FBC, U&E, eGFR, LFTs, glucose, lipidsBaseline before ART. FBC: anaemia, lymphopenia common. eGFR: TDF nephrotoxic. LFTs: ART hepatotoxicity monitoring. Glucose/lipids: metabolic effects of ARTs.eGFR <70 → TAF instead of TDF. Elevated LFTs → ART hepatotoxicity? HBV/HCV flare? Review regimen.
Toxoplasma IgG serologySeropositive patients at risk of reactivation toxoplasmosis when CD4 falls <100. Cotrimoxazole prevents both PCP and toxoplasmosis.Toxo IgG positive + CD4 <100 → cotrimoxazole prophylaxis. IgG negative → dietary advice (undercooked meat, cat faeces).
IGRA (interferon-gamma release assay)HIV increases TB reactivation risk 20-fold. Active TB must be excluded before treating latent TB. IGRA preferred over Mantoux in HIV.IGRA positive → exclude active TB (CXR + symptoms) → isoniazid preventive therapy 6 months. Active TB → manage TB first, delay ART 2 weeks.
🎓 SCA Checkpoint — Step 4TasksGlobal Skills
Investigation communication phrases
“The test we use is called a combination HIV test — it looks for two things at once and is very accurate from six weeks after exposure.”
“I am also going to check for a few other infections that often travel together — hepatitis B, hepatitis C, and syphilis.”
“There is also a genetic test we run before starting treatment that tells us which specific medications will be safe for you.”
Deductions
  • Not explaining the window period with the HIV test result
  • Omitting HBV testing in a new HIV diagnosis
  • Not ordering HLA-B*5701 before considering abacavir
  • Forgetting eGFR before initiating TDF-containing regimen
🔴 Red
Only orders HIV test in isolation. No co-infection screen. No CD4 or VL. No baseline bloods.
🟠 Amber
HIV test + some bloods but incomplete co-infection screen. Window period not explained. HLA-B*5701 omitted.
🟢 Green
Comprehensive baseline: combo test, CD4/VL, HBV/HCV/syphilis, IGRA, HLA-B*5701, eGFR/LFTs. Window period explained. Purpose of each test communicated.
5
Step 5
Reaching a Diagnosis & DDx — Explained in Plain Language
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🗣️ Explaining the Diagnosis in Plain Language — say something like this

“HIV stands for Human Immunodeficiency Virus. It is a virus that, if untreated, gradually reduces the strength of your immune system — think of your immune system as an army, and HIV slowly depletes one type of soldier called CD4 cells. The reason it used to be so serious was that without treatment, people's immune systems eventually became too weak to fight off infections. But here is what has changed completely: with modern treatment — usually one tablet a day — we can stop the virus multiplying entirely. Your immune system stays healthy. Life expectancy is the same as someone without HIV. And the virus becomes so low in your blood that it is medically impossible to pass it to anyone sexually. That last point — Undetectable equals Untransmittable, or U=U — is one of the most important things I want you to take away today.”

💬 Addressing the patient's own explanation — correcting common misconceptions

“HIV is a death sentence.”
“That was true in the 1980s and 1990s when there was no effective treatment. Today, someone diagnosed at 25 in the UK has the same life expectancy as someone without HIV. The medicines are simpler, better tolerated, and taken once daily. This is not the HIV of the past.”

“If I have HIV, I will never be able to have a relationship or children.”
“People with HIV absolutely can have healthy sexual relationships and children. With treatment, the virus becomes undetectable — it cannot be passed to a partner during sex. Pregnancy with HIV, with treatment, has less than 0.5% chance of passing the virus to the baby.”

A — Diagnosable and Manageable in Primary Care
GP / shared care

Stable HIV on ART (shared care)

VL <50, CD4 >350. Annual GP review covering CV risk, metabolic monitoring, vaccination, mental health. HIV specialist annually.

HIV negative — post-exposure reassurance

4th gen test negative at 45 days post-exposure — conclusive. Address any identified STIs, psychosocial concerns, PrEP consideration.

B — GP Initiates — HIV Specialist Confirms & Leads
Refer for specialist care

New HIV diagnosis (any stage)

GP: CD4/VL, co-infection screen, baseline bloods, counselling, safety-net. HIV specialist initiates ART — GP provides shared care thereafter.

Acute HIV seroconversion illness

Fever, rash, pharyngitis, lymphadenopathy 2–4 weeks post-exposure. Very high VL, highly infectious. HIV specialist review within days.

C — Emergency — Act Now
999 / A&E now

Pneumocystis pneumonia (PCP)

Subacute dyspnoea, dry cough, hypoxia (SpO₂ <94%). Bilateral ground-glass on CXR. CD4 usually <200. 999. IV co-trimoxazole + steroids if PaO₂ <9.3 kPa.

Cryptococcal meningitis

Headache, neck stiffness, photophobia. CD4 <100. LP: India ink, cryptococcal antigen. 999. IV liposomal amphotericin + flucytosine.

📊 HIV Staging — CDC Classification & WHO Staging with CD4 Thresholds
Stage / CategoryCD4 countClinical featuresActionStatus
WHO Stage 1 / CDC Category A>500 cells/µLAsymptomatic or persistent generalised lymphadenopathy (PGL).ART initiation — BHIVA 2022 universal recommendation. Annual monitoring.Stable
WHO Stage 2 / CDC Category A–B350–500 cells/µLMinor symptoms: seborrhoeic dermatitis, oral ulcers, herpes zoster (1 episode), recurrent URTI.ART initiation. OI prophylaxis not yet required. 6-monthly monitoring if declining.Manageable
WHO Stage 3 / CDC Category B200–350 cells/µLUnexplained weight loss >10%, oral candida, oral hairy leukoplakia, pulmonary TB, severe bacterial infections.ART urgently. Start cotrimoxazole (PCP/toxo prophylaxis). 3-monthly monitoring.Urgent
WHO Stage 4 / CDC Category C (AIDS)<200 cells/µLAIDS-defining: PCP, CMV retinitis, cerebral toxoplasmosis, cryptococcal meningitis, disseminated MAC, KS, HIV wasting, AIDS dementia, oesophageal candida, cervical cancer.ART within 2 weeks (or immediately if no OI). PCP/toxo + MAC + CMV prophylaxis. Same-day HIV specialist.Emergency
CD4 <50 (severe)<50 cells/µLHighest risk: disseminated MAC, CMV retinitis, PML. Multiple OI prophylaxis required.ART within 2 weeks. Azithromycin weekly (MAC prophylaxis). Urgent HIV specialist today.Emergency
Virological failureAny (declining)VL detectable (>200 copies/mL) on established ART. Adherence failure or resistance.Resistance genotyping urgently. Adherence assessment. HIV specialist within days.Refer urgently
🎓 SCA Checkpoint — Step 5TasksRelating to OthersGlobal Skills
Lay explanation phrases that score
“Modern HIV treatment is a single tablet a day — it stops the virus multiplying and keeps your immune system completely healthy.”
“Undetectable equals Untransmittable — U=U — which means with treatment, you cannot pass HIV to anyone sexually.”
“Someone diagnosed today has the same life expectancy as someone without HIV.”
Deductions
  • Using “AIDS” and “HIV” interchangeably without clarifying the distinction
  • Failing to mention U=U when counselling about new HIV diagnosis
  • Delivering diagnosis without checking in on the patient's emotional response
  • Not addressing the patient's pre-existing belief about HIV
🔴 Red
Tells patient “you have HIV” without explanation, analogy, or emotional check-in. Does not mention treatment. Leaves patient in terror.
🟠 Amber
Plain language used but U=U not mentioned. Diagnosis explained medically but emotional response not addressed.
🟢 Green
Diagnosis with accessible analogy. U=U explained. Normal life expectancy stated. Previous beliefs addressed. Emotional check-in at disclosure. Time given for questions.
6
Step 6
If Referral Is Needed — What the GP Does Before & During
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All newly diagnosed HIV patients should be linked to specialist HIV services immediately. The GP's role is to initiate this process and ensure the patient does not fall through the gap between diagnosis and first specialist appointment. In practice, GPs are increasingly involved in HIV shared care: prescribing repeat ARTs, managing co-morbidities, monitoring adverse effects, and providing holistic wellbeing assessment.
ConditionUrgencyWhat GP does before referralWhat GP must NOT do
New HIV diagnosis (any)Within 1–2 daysArrange CD4, VL, full co-infection screen (HBV, HCV, syphilis, IGRA), HLA-B*5701, baseline bloods. Same-day counselling and written information (THT, Positively UK). Safety-net for OI symptoms. Plan follow-up if specialist delayed.Do not initiate ART in primary care without specialist involvement. Do not disclose HIV status to third parties without consent. Do not delay referral for “more investigations.”
PEP request (within 72 hours)ImmediateRisk assess using BHIVA PEP matrix. If PEP indicated: prescribe immediately (TDF/FTC + raltegravir or TDF/FTC + dolutegravir). Do baseline HIV test, HBV, HCV, STI screen before starting.Do not delay PEP for results. Do not prescribe PEP after 72 hours. Do not prescribe as monotherapy or dual therapy.
Suspected AIDS-defining illness (OI)999 / same-day admissionO₂ for hypoxia, IV access if needed. Call ahead to admitting team — mention HIV and suspected OI. Provide available HIV history (current ART, CD4, VL).Do not start empirical broad-spectrum antibiotics without specialist guidance (may mask PCP, MAC, cryptococcus). Do not delay admission.
PrEP initiationRoutine / sexual healthNegative HIV test. Renal function (eGFR). STI screen. HBV vaccination if susceptible. Counsel on daily vs event-driven use. Available in NHS England primary care — check local pathway.Do not start PrEP in anyone with positive HIV test. Do not prescribe without renal function. Do not forget HBV vaccination.
Partner notification (index patient)Within weeksDiscuss voluntary partner notification. Offer referral to sexual health partner notification team — they can notify anonymously. Address safety concerns (partner violence) before facilitating notification.Do not breach confidentiality to notify partner without patient consent except in extreme circumstances. Do not coerce partner notification.
Virological failure on ARTWithin 1–2 weeksAdherence assessment. Repeat VL to confirm failure. Resistance genotyping — do not change regimen until genotype available. Rule out drug interactions. HIV specialist within 2 weeks.Never change a single drug in a failing regimen. Never stop all ARTs simultaneously. Do not prescribe St John's Wort while awaiting specialist review.
🎓 SCA Checkpoint — Step 6TasksRelating to Others
Referral phrases
“I am going to refer you to our specialist HIV team — they are experts at this and they will lead your treatment. My job is to make sure you get there quickly and that you are supported in the meantime.”
“The HIV clinic will contact you within a day or two — but if anything changes before then, here is who to call.”
Deductions
  • Initiating ART in a new diagnosis without HIV specialist involvement
  • Not providing support service contacts (THT, Positively UK) at referral
  • Breaching confidentiality in partner notification without consent
🔴 Red
Tries to start ART independently. No specialist referral. Patient leaves with no plan. Support services not offered.
🟠 Amber
Referral mentioned but timeline vague. Support resources not offered. Partner notification not discussed.
🟢 Green
Clear referral pathway with timeline. Support services named. Safety-net for urgent symptoms. Partner notification approached sensitively.
7
Step 7
Management — Expectation · Goals · Lifestyle · Drug Selector · Drug Cards · Psychosocial · Follow-Up · Safety-Netting
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7A — Address the patient's expectation first: validate → explain → negotiate
🤝
Never dismiss the expectation — acknowledge it, share your reasoning, then agree a shared plan
1
Validate — name their expectation

Most patients presenting with HIV concerns expect either a negative result or confirmation of their worst fear. Some expect secrecy. Some expect judgment. Name what they are hoping for before providing clinical information — this creates therapeutic alliance.

“Before I tell you about what we are going to do — what are you most hoping we can achieve today?”
2
Explain — share your clinical reasoning

HIV management in 2025 is a story of transformation. The explanation must explicitly counter the patient's likely outdated mental model. Use the CD4/immune system analogy. Emphasise U=U. Give the actual life expectancy statistic.

“HIV today is a completely manageable, chronic condition. One tablet a day stops the virus completely. Your immune system stays healthy. You cannot pass it on sexually. Life expectancy is normal.”
3
Negotiate — offer something today

Even before the HIV result returns, the patient needs something concrete: a follow-up plan, a named support contact, written information. Never allow the patient to leave with only “wait for your results.”

“Today we will do the blood tests. In the meantime, I am giving you the number for the Terrence Higgins Trust — brilliant and completely confidential. Whatever the result, you will not be doing this alone.”
Key principle: In HIV consultations, management of the patient's psychological response to the diagnosis is as clinically important as any prescribing decision. Patients who leave feeling heard, informed, and supported are far more likely to initiate ART and maintain adherence.
7B — Why treatment matters: goals tailored to this patient
Treatment goals in HIV
VL <50 copies/mL (undetectable) CD4 >500 cells/µL maintained Zero sexual transmission (U=U) Normal life expectancy achieved OI prevention (prophylaxis until CD4 >200) Co-morbidity management (CV, renal, bone) Quality of life and psychosocial wellbeing Sustained adherence (>95%)
Motivational language — tailored to the patient
“With treatment started now, your immune system will recover to normal within months. Within 3–6 months, the virus will be undetectable — at that point, you cannot pass HIV to a sexual partner. That is a fact, not just a reassurance.”
“You mentioned your children are the most important thing to you. People with HIV today see their children grow up, become grandparents, retire. This is not a disease that will stop you being there for them.”
7C — Non-medication management: mechanism + evidence + tailored advice
Lifestyle interventions in HIV are complementary to ART, not alternatives. People with HIV are at significantly higher risk of cardiovascular disease, osteoporosis, and mental health problems. Quantify these risks and link lifestyle changes to patient-valued outcomes.
🚭
Smoking cessation
Target: complete cessation
Mechanism

HIV independently doubles CV risk. Smoking adds a further 2–3x multiplier. PLHIV who smoke lose more years to CV disease than to AIDS in the modern ART era.

Practical

Offer NRT, varenicline (check ART interactions), or bupropion. NHS Stop Smoking Services referral. Frame explicitly: “For someone with HIV, stopping smoking is the single most powerful thing you can do for your long-term health.”

Reduces premature death risk ~30% in PLHIV
🫀
Cardiovascular risk reduction
Target: Framingham <10% at 10 years
Mechanism

Chronic HIV inflammation (even with undetectable VL) accelerates atherosclerosis. Some ARTs (PIs, ABC) further elevate CV risk. PLHIV have ~1.5–2x relative risk of MI vs general population.

Practical

Mediterranean diet, regular exercise (>150 min/week), BP monitoring, statin where indicated (pravastatin or rosuvastatin preferred with PIs). Annual lipid and glucose monitoring.

Diet + exercise reduces CV events ~25% in PLHIV
🦴
Bone health
Target: maintain BMD / prevent fractures
Mechanism

HIV reduces BMD by ~3–6% through immune activation. TDF-containing regimens cause additional ~3% BMD reduction in year 1. Combined fracture risk significantly elevated.

Practical

Weight-bearing exercise 3x weekly. Calcium 1000mg/day + vitamin D 800–1000 IU/day for all patients on TDF. DEXA at diagnosis if risk factors. TAF preferred over TDF.

Exercise + supplementation reduces fracture risk ~40%
🧠
Mental health and adherence
Target: PHQ-9 annually; adherence >95%
Mechanism

Depression prevalence 30–40% in PLHIV (3–4x general population). Untreated depression is the leading cause of ART non-adherence and virological failure. Treating depression directly improves VL outcomes.

Practical

PHQ-9 at every annual review. NHS Talking Therapies referral. Consider whether ART contributes (efavirenz, dolutegravir implicated). Peer support groups: Positively UK, Body & Soul, GMFA.

Treating depression improves ART adherence ~35%
💉
Vaccination
Target: optimise when CD4 >200 and VL suppressed
Mechanism

Immune response to vaccines reduced in HIV, especially when CD4 is low. Vaccine-preventable diseases more severe in PLHIV. Timing matters: vaccines most effective when CD4 >200.

Practical

Annual influenza (inactivated). Pneumococcal (PPV23 + PCV13 schedule). HAV and HBV if not immune. HPV for MSM up to age 45 (anal cancer risk). Shingles: live vaccine CONTRAINDICATED if CD4 <200 — use non-live Shingrix.

Reduces pneumonia hospitalisation ~40%
🍺
Alcohol and substance use
Target: ≤14 units/week; chemsex harm reduction
Mechanism

Alcohol accelerates hepatic fibrosis in HIV/HCV co-infection. Excess alcohol directly suppresses CD4 function. Chemsex drugs impair adherence and have dangerous ART interactions (crystal meth + ritonavir = cardiac arrhythmia risk).

Practical

AUDIT-C annually. Brief intervention for hazardous drinking. Specialist chemsex support (56 Dean Street, iCASH) for MSM. Avoid ritonavir-boosted regimens in crystal meth users.

Chemsex support reduces STI acquisition ~50%
7D — Prescribing guide: ART initiation, OI prophylaxis, PEP and PrEP
BHIVA 2022 recommends ART initiation for ALL people living with HIV regardless of CD4 count. Preferred backbone is an INSTI-based regimen. GPs do not initiate ART in newly diagnosed patients (specialist-led) but manage repeat prescriptions, OI prophylaxis thresholds, PEP, PrEP, drug interactions, and monitoring.
Preferred First-Line ART (INSTI-Based)

Bictegravir + TAF + FTC (Biktarvy) or Dolutegravir + ABC + 3TC (Triumeq)

  • INSTI backbone: high barrier to resistance, excellent tolerability
  • Biktarvy: preferred if no HLA-B*5701 or CV risk concerns
  • Triumeq: requires HLA-B*5701 negative; avoid if high CV risk (ABC)
  • DTG-based preferred in pregnancy (safer than efavirenz)
  • Start as soon as bloods available — same week as diagnosis ideally
VL check at 4 weeks, 3 months, then 6-monthly once VL <50 × 2 consecutive.
OI Prophylaxis Thresholds

Start when CD4 falls below threshold; stop when CD4 >200 on suppressive ART

  • CD4 <200: Co-trimoxazole 960mg 3×/week (PCP + toxoplasmosis)
  • CD4 <100 + toxo IgG positive: Co-trimoxazole daily (higher dose)
  • CD4 <50: Azithromycin 1.25g weekly (MAC prophylaxis)
  • Fluconazole NOT routine — only if recurrent candida
STOP prophylaxis when CD4 >200 sustained for 3 months on ART.
PEP — Post-Exposure Prophylaxis

Must start within 72 hours. 28-day course.

  • Preferred: Truvada (TDF/FTC) + raltegravir 400mg BD (28 days)
  • Alternative: TDF/FTC + dolutegravir 50mg OD
  • High-risk: receptive anal intercourse, HIV+ source not on ART
  • Start immediately while awaiting source HIV test result
Follow-up HIV test at 6 weeks and 3 months post-exposure after PEP completion.
PrEP — Pre-Exposure Prophylaxis

PrEP reduces HIV acquisition by >99% when taken correctly.

  • Daily PrEP: TDF/FTC (Truvada) or TAF/FTC — one tablet every day
  • Event-driven (2-1-1): only TDF/FTC (NOT TAF) for cisgender men
  • Requires negative HIV test, eGFR >60, STI screen, HBV vaccination
  • 3-monthly monitoring: HIV test, renal function, STI screen
NEVER start PrEP without negative HIV test. TDF in PrEP suppresses HBV — stopping can cause flare.
Long-Acting Injectable ART (Specialist-Initiated)

Cabotegravir + Rilpivirine (Cabenuva): intramuscular every 2 months

  • For patients virologically suppressed (VL <50) on oral ART
  • Addresses adherence barriers: chemsex, stigma from pill-taking, chaotic lifestyle
  • Contraindications: INSTI or NNRTI resistance; HBV co-infection (no HBV cover)
Specialist only. GP role: encourage eligible patients to discuss this option at HIV clinic.
7E — Medication selection guide: comorbidity-driven ART modification

Select patient comorbidities — ART modification guidance appears below

ART modification guidance
Universal first-line (BHIVA 2022): INSTI + 2 NRTIs
Preferred: Biktarvy (BIC/TAF/FTC) or Triumeq (DTG/ABC/3TC, requires HLA-B*5701 negative)
Key modifiers: HBV co-infection → must use TDF or TAF · CKD → TAF over TDF · Pregnancy → DTG (avoid EFV) · Active TB → rifampicin requires double-dose DTG or RAL · Psychiatric history → avoid EFV; use BIC or RPV · High CV risk → avoid ABC; use TAF/FTC-based
7F — Drug reference cards: antiretroviral therapy classes
INSTI — Integrase Strand Transfer Inhibitors
Dolutegravir (DTG), Bictegravir (BIC), Raltegravir (RAL), Cabotegravir (CAB)
✓ Recommended
First-line backbone50mg OD (DTG)
✓ Prefer when
Any new HIV diagnosis — BHIVA 2022 universal first-line recommendation
Pregnancy: dolutegravir preferred over efavirenz (BHIVA/WHO)
High barrier to resistance: particularly bictegravir (no resistance mutations selected in trials)
Once-daily dosing in single-tablet regimens improves adherence
✗ Avoid if
Polyvalent cation antacids/supplements (iron, calcium, magnesium) reduce INSTI absorption — separate by 2h or take with food
Severe psychiatric history: dolutegravir associated with depressive symptoms and suicidality — use bictegravir instead
Rifampicin: reduces DTG levels 54% — requires double-dose DTG 50mg BD or switch to raltegravir
⚠ Side effects
Neuropsychiatric: insomnia, depression, anxiety (5–10% with DTG/BIC) — more common with DTG than BIC
Weight gain: ~3–5 kg in first 2 years, particularly with DTG + TAF combination
GI: nausea, diarrhoea — usually mild, resolves in weeks
🔬 Monitor
VL at 4 weeks, 3 months, then 6-monthly once suppressed
CD4 at baseline, 3 months, annually once stable >350
Weight and BMI every 3–6 months, especially DTG + TAF
💬 Counselling

“This is the most effective HIV medication available — one tablet a day, stops the virus completely. The most important thing is taking it every day. Do not take it within 2 hours of antacids or iron tablets.”

SCA pearl: When a patient asks “why do I need to take this forever?” — explain that ART suppresses but does not cure HIV. Stopping ART causes rebound within weeks, CD4 decline, and resistance risk. U=U only applies while VL is undetectable.

TDF/FTC — Tenofovir DF + Emtricitabine
Truvada (TDF 245mg/FTC 200mg); PrEP and PEP backbone; component of Atripla
✓ Recommended
NRTI backbone1 tablet OD with food
✓ Prefer when
HBV co-infection: TDF active against both HIV and HBV — essential in co-infection
PrEP / PEP backbone — highly efficacious, well-studied, generic now available
Event-driven PrEP (2-1-1 protocol): only TDF/FTC used — not TAF
✗ Avoid if
eGFR <30 ml/min: TDF is nephrotoxic — use TAF instead
Osteoporosis/osteopenia: TDF causes BMD loss ~3% in year 1 — use TAF
eGFR 30–70: caution; consider switching to TAF; monitor renal function 3-monthly
⚠ Side effects
Nephrotoxicity: proximal tubular dysfunction (Fanconi syndrome), reduced eGFR
Bone mineral density reduction: ~3% in first year; subsequent stabilisation
GI: nausea especially in first weeks; take with food
🔬 Monitor
eGFR and urine phosphate annually (3-monthly if eGFR <70)
BMD: DEXA if risk factors; annually if TDF continued with osteoporosis
HBV surface antigen if stopping TDF — risk of HBV flare
💬 Counselling

“We will check your kidney function regularly as a precaution. Take it with a meal. If you also have hepatitis B, it is very important never to stop this medication without talking to us first.”

SCA pearl: If a patient mentions taking ibuprofen regularly — NSAIDs combined with TDF further increases nephrotoxicity risk. Ask about OTC NSAID use and substitute with paracetamol where possible.

TAF/FTC — Tenofovir Alafenamide + Emtricitabine
Descovy (TAF 25mg/FTC 200mg); component of Biktarvy, Odefsey, Symtuza
✓ Recommended
NRTI backbone1 tablet OD
✓ Prefer when
CKD / eGFR <70: TAF is renally sparing — 91% less tenofovir in plasma versus TDF
Osteoporosis/osteopenia: TAF causes significantly less BMD loss than TDF
Older patients (>50): both renal and bone advantages clinically meaningful
HBV co-infection: active against HBV with better bone/renal profile than TDF
✗ Avoid if
Event-driven PrEP (2-1-1): TAF not validated for on-demand use — TDF/FTC only
Metabolic concerns: TAF associated with greater weight gain and lipid changes than TDF
⚠ Side effects
Weight gain: more pronounced than TDF, especially with INSTI backbone (DTG + TAF)
Lipid changes: slight increase in total cholesterol and LDL vs TDF
Overall: significantly better renal and bone tolerability than TDF
🔬 Monitor
eGFR annually — nephrotoxicity much less than TDF
Lipids annually — TAF may worsen lipid profile slightly
Weight every 3–6 months — monitor for metabolic syndrome
💬 Counselling

“This is a newer version of the tenofovir component that is much gentler on your kidneys and bones. The main thing to watch is weight — some people gain a small amount, so we will keep an eye on that.”

SCA pearl: A patient asks why their prescription changed from TDF/FTC to TAF/FTC. This is a clinical upgrade for renal and bone protection, not a sign they are getting worse. Adherence patterns can continue unchanged.

ABC/3TC — Abacavir + Lamivudine
Kivexa (ABC 600mg/3TC 300mg); component of Triumeq (+ DTG)
✓ Recommended
NRTI backbone1 tablet OD
✓ Prefer when
HLA-B*5701 negative confirmed: mandatory before prescribing abacavir
Renal impairment: ABC not nephrotoxic — safe in CKD
As Triumeq (ABC/3TC/DTG): once-daily single tablet with excellent efficacy data
✗ Avoid if
HLA-B*5701 positive: absolute lifelong contraindication — rechallenge can be fatal
Active HBV co-infection: 3TC suppresses HBV but ABC does not — use TDF/TAF-based regimen
High cardiovascular risk (Framingham >20%): D:A:D study — ABC associated with ~1.9x increased MI risk
⚠ Side effects
Hypersensitivity reaction (HSR): in HLA-B*5701 carriers — fever, rash, GI, respiratory deterioration over 7 days. STOP immediately if occurs.
Cardiovascular: modest increase in MI risk in those with existing CV risk factors
Generally well tolerated in HLA-B*5701 negative patients
🔬 Monitor
No specific renal or bone monitoring required (unlike TDF)
Annual CV risk assessment — Framingham or QRISK3
HLA-B*5701 result documented clearly and prominently in all records
💬 Counselling

“We have done a genetic test to confirm this medication is safe for you. However, in the first few weeks, if you develop a fever, rash, and feel generally worse over several days — not better — stop the tablets and contact us or go to A&E immediately.”

SCA pearl: Never restart abacavir after a suspected hypersensitivity reaction — even if mild. Rechallenge in sensitised patients can be fatal within hours. Document prominently and communicate at every handover.

NNRTI — Non-Nucleoside Reverse Transcriptase Inhibitors
Rilpivirine (RPV), Efavirenz (EFV), Doravirine (DOR)
✓ Recommended
Step 2 option25mg OD (RPV)
✓ Prefer when
Rilpivirine: good tolerability; used in Odefsey (RPV/TAF/FTC) and Juluca (RPV/DTG) single-tablet regimens
Doravirine: newer NNRTI with fewer CNS side effects than efavirenz; good lipid profile
Maintenance therapy: RPV + DTG (Juluca) — a 2-drug regimen for suppressed patients
✗ Avoid if
PPIs/antacids with rilpivirine: gastric acid required for RPV absorption — PPIs reduce RPV AUC by 40%
Efavirenz in psychiatric history: CNS toxicity (vivid dreams, depression, suicidality) — contraindicated
Rifampicin: strong inducer, reduces NNRTI levels significantly
⚠ Side effects
Efavirenz: vivid dreams, dizziness, depression — take at night; persists in ~10% long-term
Rilpivirine: generally well tolerated; headache, insomnia, rash — mild
Class rash — rarely Stevens-Johnson syndrome (especially nevirapine)
🔬 Monitor
Rilpivirine: VL — low barrier to resistance if baseline VL >100,000; use INSTI if high VL
Efavirenz: lipids — EFV can increase LDL and triglycerides
Neuropsychiatric symptoms with efavirenz at every review
💬 Counselling

“For rilpivirine: this tablet must be taken with a meal of at least 500 calories every time — and do not take it with antacids or acid-suppressing tablets. For efavirenz: take at bedtime; some people have unusual dreams initially that usually settle within weeks.”

SCA pearl: A patient on efavirenz reports disturbing dreams and low mood for 3 months. This is EFV CNS toxicity — persistent in ~10%. Refer to HIV specialist for regimen switch to INSTI-based therapy. Do not dismiss as unrelated to ART.

Boosted Protease Inhibitors (PI/r or PI/c)
Darunavir/cobicistat (DRV/c 800/150mg); Darunavir/ritonavir (DRV/r)
✓ Recommended
Special situations800/150mg OD (DRV/c)
✓ Prefer when
High baseline resistance or suspected transmitted drug resistance
Darunavir: high barrier to resistance — no single mutation confers full resistance
Salvage therapy when INSTI and NNRTI resistance present
✗ Avoid if
St John's Wort, rifampicin: reduce PI levels dramatically — contraindicated
Crystal methamphetamine: ritonavir/cobicistat markedly increase meth levels — risk of fatal cardiac arrhythmia
Statins: simvastatin and lovastatin contraindicated with cobicistat/ritonavir; use rosuvastatin or pravastatin
⚠ Side effects
Metabolic: dyslipidaemia (elevated TG, LDL), lipodystrophy, insulin resistance
GI: diarrhoea, nausea — common, often persistent
Drug interactions: extensive CYP3A4 inhibition — check ALL co-prescriptions via hiv-druginteractions.org
🔬 Monitor
Fasting lipids every 3–6 months — PI-associated dyslipidaemia significant
Glucose/HbA1c annually — insulin resistance
LFTs: ritonavir can elevate transaminases, especially in HCV co-infection
💬 Counselling

“This medication has many interactions with other drugs — please check with us or the pharmacist before taking anything new, including over-the-counter medicines and herbal remedies. St John's Wort must be completely avoided.”

SCA pearl: Before prescribing ANY new medication to a patient on boosted PI (ritonavir or cobicistat), use the Liverpool HIV Drug Interaction Checker. Common dangerous interactions: statins, erectile dysfunction drugs, PPIs, and anticoagulants.

7G — Psychosocial impact of the diagnosis: disclosure, work, relationships & daily life
🪶
Living Well with HIV — What the Diagnosis Changes, and What It Does Not
HIV diagnosis in 2025 does not define a person's life trajectory — but the psychosocial consequences can be as disabling as any physical complication if left unaddressed. People with HIV face a unique combination of medical management, stigma navigation, legal disclosure obligations, and identity adjustment. Primary care is uniquely positioned to address these consequences holistically.
💔
Partner Disclosure and Relationships

There is no legal obligation to disclose HIV status to sexual partners, but there is an ethical one (BHIVA, GMC). Patients on ART with undetectable VL cannot sexually transmit HIV (U=U) — this changes the disclosure calculus for many patients.

Partner notification services at GUM clinics can notify past partners confidentially and anonymously on the patient's behalf, without revealing the index patient's name.

Reckless transmission of HIV is a criminal offence in England and Wales under the Offences Against the Person Act 1861.

“I want to talk about what this means for your relationship — there is actually a lot of good news here.”
🏢
Employment and Occupational Impact

HIV is a protected characteristic under the Equality Act 2010 — from the point of diagnosis, even before symptoms develop. Employers cannot discriminate in hiring, promotion, or dismissal on grounds of HIV status.

Healthcare workers with undetectable VL can perform most clinical roles. EPPs (exposure-prone procedures) require UKAP regulatory approval — undetectable VL now permits most EPPs.

No obligation to disclose HIV status to employers in most occupations. Exception: armed forces.

“You do not have to tell your employer. HIV is legally a disability from diagnosis, so you are protected from discrimination.”
👶
Pregnancy, Fertility and Parenthood

Women with HIV can have healthy pregnancies and children with extremely low risk of vertical transmission (<0.5% with ART). Vaginal delivery is safe with undetectable VL at 36 weeks; elective CS for VL >50.

Breastfeeding: BHIVA 2023 advises against breastfeeding in the UK due to residual transmission risk even with ART. Formula feeding is supported and safe in the UK.

Male HIV: if undetectable on ART (U=U), natural conception is safe. Sperm washing no longer recommended by BHIVA.

“People with HIV absolutely can have children — with modern treatment, the risk of passing it on is less than 1 in 200.”
✈️
Travel and Immigration

Over 50 countries have travel or immigration restrictions for people with HIV. NAM AIDSmap and UNAIDS resources list country-specific restrictions. These are not always transparently declared.

ART supply for travel: carry more than enough supply (+1 week extra), original labelled packaging, letter from HIV clinic. Airport security may inspect medications.

Travel insurance: HIV must be declared as a pre-existing condition. With stable HIV on ART, most mainstream insurers cover it without significant premium increases.

“There are some countries with entry restrictions for people with HIV — I would encourage you to check before travelling.”
💰
Insurance and Financial Implications

Life insurance: PLHIV can obtain life insurance. With modern life expectancy data, some mainstream insurers now offer standard rates to people with well-controlled HIV. Specialist HIV-friendly insurers exist.

Critical illness insurance: typically excludes HIV as a pre-existing condition. Income protection may be obtained via specialist brokers.

Welfare benefits: PLHIV with significant impairment may be eligible for PIP or ESA. HIV Scotland, THT, and NAM can provide welfare rights advice.

“Insurance has become much more accessible for people with HIV — it is worth speaking to a specialist HIV-friendly broker.”
🧠
Mental Health, Stigma and Identity

HIV-associated neurocognitive disorder (HAND): subtle cognitive changes affect ~15–50% of PLHIV. Regular cognitive screening at annual review. Not AIDS dementia — often manageable.

The emotional impact involves grief (for an imagined HIV-negative future), adjustment to chronic condition, and navigation of stigma. This is a normal response requiring support, not just reassurance.

Peer support is consistently the most effective intervention for HIV-related mental health: Positively UK, Body & Soul, THT, GMFA, NAM.

“What you are feeling is completely normal — and there is a community of people who have been where you are and can really help.”
7H — Follow-up schedule
1
Immediate (same-day / next-day) — New Diagnosis

GP-initiated: CD4, VL, full co-infection screen, HLA-B*5701, FBC, U&E, LFTs, lipids. Counselling, written information, support service contacts (THT, Positively UK). HIV specialist contact initiated. PEP: prescribe immediately if within 72h.

New diagnosisPEP start
2
2–4 weeks — ART Initiation / Early Tolerance Check

HIV specialist initiates ART. GP reviews: symptom tolerance, nausea/rash, adherence, mental health. Repeat VL at 4 weeks to confirm early viral suppression trajectory. PEP completion: HIV test at 6 weeks post-exposure.

ART startedPEP complete
3
3 months — First Virological Milestone

VL should be <200 copies/mL (ideally <50) by 3 months on ART. CD4 check: expect rise ~100–150 cells/µL/year. FBC, renal function, LFTs. Adherence assessment. Partner notification — has patient acted? STI re-screen.

VL targetAdherence
4
6 months — Confirm Viral Suppression / U=U

Confirmed undetectable VL (<50) x 2 = viral suppression milestone. U=U applies — patient can be counselled on sexual transmission risk. STI re-screen (3-monthly for MSM). Transition to 6-monthly HIV clinic monitoring.

U=U confirmed6-monthly monitoring
5
Annual — Comprehensive Shared Care Review

Annual: VL, CD4, FBC, U&E/eGFR, LFTs, fasting lipids, glucose, HbA1c, BP, BMI, smoking, PHQ-9, AUDIT-C, sexual health screen. Vaccination review (influenza, pneumococcal, HBV, HPV, COVID). Cervical smear annually for women with HIV. DEXA if TDF and age >50.

Annual reviewCancer screeningVaccinations
7I — Monitoring: the VL-CD4-Comorbidity rule + treatment targets

Memory rule

New diagnosis: VL + CD4 + full screen within 1 week. On ART: VL at 4 weeks, 3 months, then 6-monthly until VL <50 × 2, then annually if stable. CD4: annually once >350 and suppressed. Renal (TDF): annually, 3-monthly if eGFR borderline. Cervical smear: annually for all women with HIV. HBV: check anti-HBs titres annually; re-vaccinate if <10 IU/L.

Drug class / testWhat to checkTimingAction threshold
Viral load (all ART)Virological suppression4 wks, 3 months, 6 months, annuallyVL >200 at 3 months → adherence; VL >50 stable → resistance test + specialist
CD4 countImmune recovery; OI prophylaxis thresholdBaseline, 3 months, annually if >350CD4 <200 → start cotrimoxazole; <50 → azithromycin + ART urgently
eGFR + urine phosphate (TDF)TDF nephrotoxicity; proximal tubular damageBaseline, 3 months, annuallyeGFR <70 → switch to TAF; phosphaturia + glucosuria → Fanconi syndrome
LFTs (all ART, especially PIs)Hepatotoxicity; HBV/HCV flareBaseline, 3 months, annuallyALT >5× ULN → hold ART; assess for OI hepatitis, HBV/HCV reactivation
Fasting lipids + glucoseART metabolic effects; CV riskBaseline, annuallyLDL >3 + Framingham >10% → statin (rosuvastatin/pravastatin preferred with PIs)
HBV surface antigen + VL (HBV co-infected)HBV activity; flare risk if drug switchedAnnually; and before any TDF/TAF switchHBsAg positive + TDF/TAF being stopped → specialist review mandatory
Patient groupVL targetCD4 target / threshold
All PLHIV on ART<50 copies/mL (undetectable)CD4 >350 cells/µL (aim >500)
CD4 <200 at baseline<50 by 6 monthsCD4 rising >100/year expected
Pregnancy<50 by 36 weeks (ideally <20 by delivery)Not threshold-dependent in pregnancy
U=U (sexual transmission)VL <200 copies/mL sustainedCD4 not independently required for U=U
Stop cotrimoxazole prophylaxisVL suppressedCD4 >200 for >3 months on ART
Stop MAC prophylaxis (azithromycin)VL suppressedCD4 >100 for >3 months on ART
PrEP monitoring (HIV negative at-risk)Confirm HIV negative (3-monthly test)HIV test mandatory every 3 months
7J — Safety-netting: exact phrases + medico-legal rationale

⚠ Three scenario-specific phrases — use these verbatim

🔴 Emergency — signs of opportunistic infection in known or suspected HIV
“If you develop any of the following, go to A&E immediately or call 999 — do not wait for an appointment: difficulty breathing or a dry persistent cough; a severe headache that feels different from any headache you have had before, especially with a stiff neck or sensitivity to light; confusion; or any sudden change in your vision. These can be signs of serious infections that need hospital treatment right away.”
Naming specific symptoms (not vague “feel worse”) creates a clinical record the patient was explicitly warned about OI presentations. This is medico-legally protective in the event of delayed PCP or cryptococcal meningitis diagnosis.
💊 Medication — starting ART or PEP for the first time
“In the first few weeks of these tablets, you might feel a bit nauseous or tired — this is very common and usually settles after 2–3 weeks. However, if you develop a skin rash, yellowing of your skin or eyes, or if you feel worse each day rather than the same or better, please contact us urgently that day. For abacavir specifically: if you develop fever, rash, and feeling unwell simultaneously, stop the tablets immediately and come straight in or go to A&E.”
Pre-warning about expected side effects reduces ART discontinuation from anxiety. The abacavir hypersensitivity warning is essential — it is a potentially fatal reaction requiring documentation that the patient was warned.
🟠 Drug interactions — taking anything new with ART
“HIV medications have many interactions with other drugs — including things you might pick up at a pharmacy without a prescription, like St John's Wort or herbal remedies. Before you start anything new — prescription or over the counter — please check with us or the pharmacist first, or use the Liverpool Drug Interactions Checker online. This is one of the most important things you can do to keep your treatment working.”
Drug interactions with ARTs (especially ritonavir/cobicistat) cause virological failure, toxicity, and sometimes fatal events. Documenting that the patient was warned about drug interactions is essential medico-legally.
Why safety-netting matters beyond clinical care in HIV
Delayed PCP diagnosis is a leading cause of HIV-related preventable death — documented OI safety-net is essential
Abacavir hypersensitivity warning must be documented at every prescription — rechallenge is life-threatening
Drug interaction warning is medico-legally protective when serious ART interaction causes harm
Mental health safety-netting at new diagnosis (suicidality risk) must be explicitly documented
Partner notification discussion must be documented — GMC guidance requires it even if patient declines
Window period explanation at negative test prevents assumption of “all clear” prematurely
Test result4th gen result typically 1–7 days. Clinic contacts with result — patient should not have to chase.
HIV specialistAll new positive results: contact within 1–2 working days. GP initiates referral at time of result.
PEP follow-up28-day completion, HIV test at 6 weeks and 3 months, STI screen, consider PrEP discussion
🎓 SCA Checkpoint — Step 7 (Final)TasksRelating to OthersGlobal Skills
Closing the consultation
“To summarise what we have agreed: blood tests today, HIV specialist referral in the next day or two, and here is the Terrence Higgins Trust number for support in the meantime.”
“U=U — Undetectable equals Untransmittable. I want you to remember that.”
“You do not have to tell your employer — and if HIV is detected, you are protected by the Equality Act from discrimination.”
“Before you go — is there anything else on your mind, or anything we have not covered that you wanted to ask?”
“If your breathing changes, or you get a severe headache, or develop a rash while taking treatment — please go to A&E straightaway.”
Deductions — closing
  • Not mentioning U=U at all in a new diagnosis consultation
  • Failing to address the patient's specific relationship/disclosure concern
  • Not naming the follow-up plan explicitly (who, when, what)
  • Skipping the closing question (“anything else?”)
  • Using the word “AIDS” to describe current status without clarifying distinction
  • Moralising about behaviour or implying lifestyle blame
Tasks domain — full criteria
  • Exposure route and timing established; PEP eligibility assessed
  • Acute HIV symptoms asked about (seroconversion illness)
  • Red flags (OI) screened and safety-netted with named symptoms
  • 4th gen test and window period explained correctly
  • U=U and normal life expectancy stated explicitly
  • ART and specialist referral pathway explained with timeline
Relating to Others — full criteria
  • Non-judgmental framing throughout — no lifestyle blame
  • Patient's ideas about HIV named and corrected if outdated
  • Specific concern (relationship/disclosure/employment) named and addressed
  • Expectation validated and met or negotiated
  • Stigma directly acknowledged (“HIV carries an unfair stigma — the reality today is very different”)
  • Emotional response validated — space given; closing question asked
🔴 Red — failing management
No U=U. No referral plan. Emotional impact not addressed. Patient leaves confused. Judgmental language used.
🟠 Amber — borderline
U=U mentioned but not explained. Referral planned but timeline vague. Safety-netting generic. Specific psychosocial concern raised but not fully addressed.
🟢 Green — passing
U=U explained clearly and linked to patient's relationship concern. Normal life expectancy stated. Named specialist referral with timeline. Specific OI symptoms safety-netted. Support services provided. Closing question asked.
HIV — SCA Consultation Scorecard
Based on the official SCA Consultation Tool · RAG self-assessment · Use after every practice consultation
0/ 33 pts
🌐
Global Skills
Structure, language, responsiveness
0/7
✓
Tasks
Clinical reasoning, diagnosis, management
0/15
🤝
Relating to Others
Communication, rapport, shared decision making
0/11
RAG Self-Assessment Guide
🔴 Red — not achieved
No open question. Jumps to tests. ICE absent. Judgmental language. U=U not mentioned. Patient leaves more frightened than when they arrived.
🟠 Amber — partially achieved
Some ICE but not all three domains. U=U mentioned but not explained in context of relationship. Safety-netting generic. Follow-up plan vague.
🟢 Green — fully achieved
All three ICE domains addressed. U=U explained and linked to patient's specific concern. Life expectancy normalised. Named OI symptoms in safety-net. Named follow-up. Non-judgmental. Closing question asked.
011172533
Fail
Borderline
Pass
Strong pass
📋
Complete the checklist above to see your score interpretation and feedback
“I found out yesterday that someone I slept with three weeks ago may have HIV. I have been looking it up all night. I am absolutely terrified. Please — I do not know what to do.”
Who you are

Fatima Osei, 34. Secondary school teacher. In a committed relationship (2 years). Had unprotected sex with a casual contact 3 weeks ago while her partner was away — a one-off she deeply regrets. Found out via a mutual friend yesterday that this person may be HIV positive. She has not told her partner. No significant PMH. Not on any regular medications. Non-smoker. Drinks occasionally.

Hidden agenda

Fatima's deepest fear is NOT “do I have HIV?” — it is “will I have to tell my partner about the affair?” She believes having HIV means disclosing to her partner, which will end her relationship. She also worries about her job — she works with children and fears she will have to disclose to her school. She believes HIV is still a death sentence based on media coverage.

Symptoms if asked directly
  • No fever, no rash, no lymphadenopathy — all negative if asked
  • Mild sore throat for 2–3 days — will mention if specifically asked
  • Extreme tiredness — attributes to stress and lack of sleep
  • No genital symptoms, no dysuria, no weight loss, no night sweats
  • No IVDU, no needlestick exposure, not pregnant
Lifestyle + bonus details
  • Does not know if the person is actually HIV positive — it was rumour via a friend
  • Has never had an HIV test before
  • Was not using drugs or alcohol at the time of the encounter
  • Not on any contraception (not needed in her main relationship)
  • Bonus (only if rapport excellent and specifically asked about employment): worried children's services will be informed about HIV
“So if the test comes back positive — does that mean I have to tell my partner? And my school? He will leave me. I cannot lose everything over this.”

Resolution: Fatima accepts the plan if the candidate: (1) explains clearly there is no legal obligation to disclose to her partner — especially if VL becomes undetectable (U=U); (2) confirms she does NOT have to disclose to her employer (Equality Act 2010); (3) explains the HIV test process and window period (3 weeks = within window, needs repeat at 45 days); and (4) provides a named follow-up plan and support service contact.

🏥
Clinic Quick Reference
HIV — Clinical Decision Framework
NICE NG60 · BHIVA 2022 · CKS 2024
▼expand
🚦 1 — Triage Algorithm
HIV presentation → Assess: PEP window open? OI features? CD4 known?
↓
🔴 Emergency — 999 / A&E
  • Hypoxia + dry cough (PCP)
  • Headache + neck stiffness (cryptococcal meningitis)
  • Focal neurology (CNS toxoplasmosis / lymphoma)
  • Visual field loss (CMV retinitis)
  • Acute suicidal crisis at new diagnosis
999 / same-day A&E now
🟠 Urgent — same-day
  • PEP request within 72h — prescribe NOW
  • New HIV positive result — specialist contact today
  • Known HIV, CD4 <200, not on ART
  • Acute seroconversion illness (fever + rash)
  • Virological failure on ART (VL >200)
HIV specialist same-day
🟢 Routine — planned
  • Stable HIV, VL undetectable (annual review)
  • HIV test (asymptomatic, no acute exposure)
  • PrEP initiation or monitoring
  • ART repeat prescription in shared care
GP / sexual health clinic
🧬 2 — Diagnostic Pathway
HIV Staging at Diagnosis
CD4 >500: Stage 1 — Asymptomatic, start ART
CD4 350–500: Stage 2 — Minor symptoms, start ART
CD4 200–350: Stage 3 — Cotrimoxazole prophylaxis + ART urgently
CD4 <200: Stage 4 (AIDS) — OI prophylaxis + ART within 2 weeks
CD4 <50: Highest risk — ART within 2 weeks + azithromycin + specialist today
Baseline Investigations (New Diagnosis)
HIV 4th gen Ag/Ab combo test + HIV RNA if AHI suspected
CD4 count + CD4% · Viral load (copies/mL)
HBsAg + anti-HBc + anti-HBs · HCV antibody
Syphilis serology (TPHA/VDRL) · Full STI screen
HLA-B*5701 · Toxoplasma IgG · IGRA (latent TB)
FBC · U&E/eGFR · LFTs · Fasting lipids · Glucose/HbA1c
📊 3 — Key Numbers
CD4 <200
AIDS threshold (cells/µL); start cotrimoxazole
<50 copies
Undetectable VL target — U=U confirmed
72 hours
PEP initiation window from exposure
45 days
4th gen test window period (>99.9%)
28 days
PEP course duration
2 weeks
ART start if CD4 <50
3 months
First VL milestone on ART (target <50)
<0.5%
Vertical HIV transmission with PMTCT
>99%
PrEP efficacy (daily use)
1 in 8
People with HIV unaware of status in UK
eGFR <70
Switch TDF → TAF threshold
U=U
Undetectable = Untransmittable; core counselling
💊 4 — ART Decision & Choice
First-Line ART (BHIVA 2022)
Biktarvy (BIC + TAF + FTC) — once daily, high resistance barrier
Triumeq (DTG + ABC + 3TC) — requires HLA-B*5701 negative
Odefsey (RPV + TAF + FTC) — if baseline VL <100,000
Start ART in ALL PLHIV regardless of CD4 count — BHIVA 2022
Comorbidity Modifications
HBV co-infection: must include TDF or TAF — never stop
CKD / eGFR <70: TAF over TDF; 3-monthly renal monitoring
Pregnancy: DTG preferred; avoid EFV in first trimester
Active TB + rifampicin: double-dose DTG 50mg BD or use RAL
Psychiatric history: avoid EFV; use BIC or RPV
High CV risk: avoid ABC; use TAF/FTC-based regimen
⚠ 5 — Safety Netting & Follow-Up
🔴 Emergency — OI symptoms
“Difficulty breathing, severe headache + neck stiffness, confusion, or sudden visual change — A&E immediately, do not wait.”
💊 ART side effects
“Rash + fever worsening daily (abacavir HSR) — stop tablets, A&E immediately. Nausea in weeks 1–3 is normal and will settle.”
🟠 Drug interactions
“Check ALL new medications (inc OTC, herbal) before starting. St John's Wort absolutely contraindicated with all ART.”
Follow-up timeline
1
Same day: Blood tests, counselling, THT contacts, HIV specialist referral
2
2–4 weeks: ART initiation (specialist), tolerance check, early VL
3
3 months: VL target <50, CD4 check, adherence, STI re-screen
4
6 months: Confirm suppression, U=U counselling, 6-monthly monitoring
5
Annually: Full shared care review, vaccinations, cancer screening
📌 Cervical smear annually for ALL women with HIV
🔬 6 — Monitoring & Red Flags
TestIndicationTimingAction threshold
Viral loadVirological suppression4 wks, 3 m, 6 m, annuallyVL >200 on ART → adherence check + resistance genotype
CD4 countImmune recovery; OI prophylaxis3 m → annually once >350CD4 <200 → cotrimoxazole; <50 → azithromycin + urgent ART
eGFR (TDF)TDF nephrotoxicityAnnually (3-monthly if borderline)eGFR <70 → switch to TAF; Fanconi signs → urgent review
LFTsART hepatotoxicity; HBV/HCV3 m → annuallyALT >5×ULN → hold ART, specialist urgently
Lipids + glucoseART metabolic effects; CV riskAnnuallyLDL >3 + Framingham >10% → statin (pravastatin preferred with PIs)
Cervical smear (women)HPV-driven cancer elevated riskAnnuallyAny abnormality → colposcopy; follow NHSCSP pathway
🔴 Red flags / 999: Hypoxia + dry cough (PCP) · Headache + neck stiffness (cryptococcal) · Focal neurology (CNS OI) · Visual change (CMV) · Suicidal crisis
🛡️ Safeguarding: Reproductive coercion · HIV in adolescents (exploitation) · Trafficking · Cognitive impairment + sexual activity · Chemsex vulnerability
🎓
SCA Exam Quick Reference
SCA Consultation Blueprint
Tasks · Relating to Others · Global Skills · RAG guide
▼expand
🕐 12-Minute Consultation Flow
0–2 min
Open & Explore
“I can see from your message that something has happened that has really been worrying you. Can you tell me in your own words what has been happening?”
Reference existing eConsult/case card. Let patient lead. Resist urgency to ask exposure questions immediately.
Global SkillsRelating to Others
✗ Re-asking what was in eConsult · Jumping to exposure questions before opening broadly
2–5 min
Targeted History + ICE
“What is your biggest worry right now — sometimes it is not just the medical side of things?”
Establish: exposure timing (PEP window?), route, source status, seroconversion symptoms. All 3 ICE domains: Ideas (what HIV means to them), Concerns (specific fear), Expectations.
TasksRelating to Others
✗ Only asking medical questions · Missing ICE · Judgemental framing
5–7 min
PMH + Red Flags
“Have you had any difficulty breathing, severe headaches, or changes in your vision? Any other medical conditions or medications?”
PMH: HBV, HCV, TB, psychiatric, renal disease, medications. Red flags: OI symptoms. Note PrEP status. Safeguarding screen if young or coercion suspected.
TasksGlobal Skills
✗ Missing red flag OI symptoms · Not asking about current medications and interactions
7–10 min
Diagnosis + Management Plan
“HIV today is a completely manageable condition — one tablet a day stops the virus. And when the virus is undetectable, you cannot pass it on sexually. That is U=U. Life expectancy is the same as without HIV.”
Address their specific ideas. Correct outdated HIV beliefs. Explicitly state normal life expectancy. Address disclosure and employment concerns. Explain specialist referral pathway.
TasksRelating to Others
✗ Not mentioning U=U · Not addressing employment concern · Initiating ART without specialist
10–12 min
Safety-Net + Close
“If you develop difficulty breathing, a very severe headache with neck stiffness, or sudden visual change — A&E immediately. Before you go, is there anything else on your mind?”
Summarise agreed plan. Named follow-up (HIV clinic 1–2 days). Named OI symptoms. Support service contacts (THT). Closing question. Check understanding.
TasksRelating to OthersGlobal Skills
✗ Generic safety-netting · Skipping closing question · No named follow-up
🟢🟠🔴 RAG Scoring — All 3 Domains
Tasks Domain
🟢
Exposure assessed; PEP window calculated; U=U explained; life expectancy normalised; named follow-up given; specific OI symptoms safety-netted
🟠
Exposure partially assessed; U=U mentioned but not explained; follow-up vague; some red flags missed
🔴
No PEP eligibility check; no U=U; no OI red flags; no specific follow-up; clinical reasoning absent
Relating to Others
🟢
All 3 ICE domains named and addressed; stigma proactively addressed; employment/disclosure concern answered; non-judgmental throughout
🟠
Ideas asked but not addressed; concerns named but not followed through; emotional response not validated
🔴
No ICE; judgemental language; diagnosis delivered without empathy; patient fears not addressed at all
Global Skills
🟢
Open question first; data gathering by 7 min; no jargon; used existing case info; closing question asked
🟠
Reasonable structure but jargon used; data gathering overruns; closing question skipped
🔴
No open question; unstructured; jargon throughout; did not use existing information
💬 Key Phrases — ICE, Diagnosis & Plan
Ideas
“What do you understand about HIV — what does it mean to you if someone has it these days?”
Concerns
“What is your biggest worry right now? Sometimes it is not just the medical side of things.”
Expectations
“What were you hoping we could achieve today — what would make this consultation feel worthwhile?”
Validate
“It is completely understandable to feel terrified right now — what you are feeling makes total sense.”
Explain U=U
“When the virus is undetectable in your blood, you cannot pass it to anyone sexually. That is medically proven — U=U.”
Close
“Before you go — is there anything else on your mind, or anything we have not covered today?”
🚫 9 Danger Zones — Instant Deductions
✗
Re-asking what was in the eConsult→ Reference existing info in your opener
✗
Skipping ICE in HIV consultation→ All 3 ICE domains essential every time
✗
Not mentioning U=U→ State U=U explicitly and link to patient's specific relationship concern
✗
Failing to calculate PEP eligibility→ Always establish exact exposure timing; <72h = PEP NOW
✗
Judgmental language or implied lifestyle blame→ Non-judgmental throughout; HIV is not a moral failing
✗
Delivering diagnosis without emotional check-in→ Pause; allow silence; validate before management
✗
Generic safety-netting only→ Name specific OI symptoms: dyspnoea, headache + neck stiffness, visual change
✗
Initiating ART in primary care without specialist→ GP initiates referral; HIV specialist initiates ART
✗
Skipping closing question→ “Is there anything else on your mind?” is mandatory before closing
💊 ART Quick-Pick
Universal first-line
→
INSTI + 2 NRTIs
Biktarvy or Triumeq
HBV co-infection
→
Must use TDF/TAF
Never stop in HBV
CKD / eGFR <70
→
TAF over TDF
91% less renal exposure
Pregnancy
→
DTG preferred
Avoid EFV in 1st trimester
Active TB + rifampicin
→
DTG 50mg BD
Or switch to RAL
Psychiatric history
→
BIC or RPV
Avoid EFV and DTG
High CV risk
→
Avoid ABC
Use TAF/FTC-based
⛔ St John's Wort contraindicated with ALL ART · Never change single drug in failing regimen · Never stop all ARTs simultaneously · Always check Liverpool HIV Drug Interaction Checker

HIV · GP Clinical Reasoning Framework v2 · NICE NG60 (2016, updated 2020) · BHIVA Guidelines for the Treatment of HIV-1-Positive Adults with Antiretroviral Therapy (2022) · BHIVA Guidelines for the Management of HIV in Pregnancy and Postpartum (2023) · NICE CKS HIV Infection and AIDS (2024) · BHIVA Standards of Care for People Living with HIV (2018)

v2: Clinical stem · Open Q first · ICE in all modes · Psychosocial (1E: causes; 7G: consequences) · Lay language DDx (Step 5) · Safeguarding (Step 1) · Expectation management (7A) · SCA RAG checkpoints after every step · SCA Scorecard as standalone section · Dual summaries (Clinic + SCA)

Teaching clinicians why each step matters — not just what to do · Always consult current BNF/SPC and BHIVA guidelines · For ART prescribing use hiv-druginteractions.org · Clinical judgement takes precedence over any framework

Reviewed: July 2026 · citations verified against current NICE / UK guidance